Telemedicine for contraceptive counseling: An exploratory survey of US family planning providers following rapid adoption of services during the COVID-19 pandemic

Telemedicine for Adolescent and Young Adult Long-Acting Reversible Contraception Post-insertion Visits: Outcomes over 1 Year

STUDY OBJECTIVE

Telemedicine for long-acting reversible contraception (LARC) care is understudied given the rapid implementation of these services in response to the COVID-19 pandemic. We compared outcomes over 1 year of adolescents and young adults (AYAs) attending a LARC post-insertion visit via telemedicine vs in person.

DESIGN

Longitudinal cohort study.

SETTING

Four academic adolescent medicine clinics in the United States.

PARTICIPANTS

AYAs (ages 13-26 years) who received LARC between 4/1/20 and 3/1/21 and attended a post-insertion visit within 12 weeks.

INTERVENTIONS

none.

MAIN OUTCOME MEASURES

Outcomes over 1 year were compared between AYAs who completed this visit via telemedicine vs in person. We analyzed the data using descriptive statistics, bivariate analyses, and regression models.

RESULTS

Of 194 AYAs (ages 13.9-25.7 years) attending a post-insertion visit, 40.2% utilized telemedicine. Menstrual management (odds ratio (OR) = 1.02; confidence interval (CI): 0.40-2.60), acne management (P = .28), number of visits attended (relative risk (RR) = 1.08; CI: 0.99-1.19), and LARC removal (P = .95) were similar between groups. AYAs attending via telemedicine were less likely than those attending in person to have STI testing (P = .001). Intrauterine device expulsion or malposition and arm symptoms with implant in situ were rare outcomes in both groups.

CONCLUSION

Roughly 40% of AYAs attended a post-insertion visit via telemedicine during the first year of the COVID-19 pandemic and had similar 1-year outcomes as those attending in person. The decreased likelihood of STI testing for those using telemedicine highlights the need to provide alternative options, when indicated, such as asynchronous or home testing. Our results support the use of telemedicine for AYA LARC post-insertion care and identify potential gaps in telemedicine care which can help improve clinic protocols.

Evaluation of telemedicine for contraceptive counseling given to pregnant women during the COVID-19 pandemic: A randomized controlled trial

In this study, we aimed to evaluate the impact of telemedicine for contraceptive counseling on knowledge levels and satisfaction with Family Planning Services. We collected data from 77 third-trimester pregnant women using a personal information form, Family Planning Knowledge Questionnaire, and the Satisfaction with Family Planning Services Scale and compared the data using chi-square test, Fisher's exact chi-square test, t-test for independent and dependent groups and Mann-Whitney U analysis. The experimental group participants (n = 37) received two informative video visits for contraceptive counseling, while the women in the control group (n = 40) received routine face-to-face Family Planning Services at their primary health care center. Participants in the experimental group showed a greater increase in knowledge levels and higher satisfaction with Family Planning Services than those in the control group (p < 0.05). In conclusion, we determined that telemedicine for contraceptive counseling is a promising option even beyond the pandemic.

Use of telemedicine to obtain contraception among young adults: Inequities by health insurance

OBJECTIVES

The objective of this study was to describe the use of telemedicine for contraception in a sample of young adults and examine differences by health insurance coverage.

STUDY DESIGN

We analyzed survey data collected from May 2020 to July 2022 from individuals at risk of pregnancy aged 18 to 29 recruited at 29 community colleges in California and Texas. We used multivariable mixed-effects logistic regression models with random effects for site and individual to compare the use of telemedicine to obtain contraception by insurance status, sociodemographic characteristics, and state.

RESULTS

Our analytic sample included 6465 observations from 1630 individuals. Participants reported using a contraceptive method obtained through telemedicine in just 6% of observations. Uninsured participants were significantly less likely than those privately insured to use contraception obtained through telemedicine (adjusted odds ratio [aOR], 0.54; 95% confidence interval [CI], 0.31-0.97), as were participants who did not know their insurance status (aOR, 0.54; 95% CI, 0.29-0.99). Texas participants were less likely to use contraception obtained via telemedicine than those in California (aOR, 0.42; CI: 0.25-0.69).

CONCLUSIONS

Few young people in this study obtained contraception through telemedicine, and insurance was crucial for access in both states.

IMPLICATIONS

Although telemedicine holds promise for increasing contraceptive access, we found that few young adults were using it, particularly among the uninsured. Efforts are needed to improve young adults' access to telemedicine for contraception and address insurance disparities.

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.

Changes in Commercial Insurance Claims for Contraceptive Services During the Beginning of the COVID-19 Pandemic-United States, January 2019-September 2020

OBJECTIVE

We describe changes in commercial insurance claims for contraceptive services during the beginning of the COVID-19 pandemic.

METHODS

We analyzed commercial insurance claims using IQVIA PharMetrics Plus data from more than 9 million U.S. females aged 15-49 years, enrolled during any month, January 2019 through September 2020. We calculated monthly rates of outpatient claims for intrauterine devices (IUDs), implants, and injectable contraception and monthly rates of pharmacy claims for contraceptive pills, patches, and rings. We used Joinpoint regression analysis to identify when statistically significant changes occurred in trends of monthly claims rates for each contraceptive method. We calculated monthly percentages of claims for contraceptive counseling via telehealth.

RESULTS

Monthly claims rates decreased for IUDs (-50%) and implants (-43%) comparing February 2020 with April 2020 but rebounded by June 2020. Monthly claims rates for injectables decreased (-19%) comparing January 2019 with September 2020, and monthly claims rates for pills, patches, and rings decreased (-22%) comparing July 2019 with September 2020. The percentage of claims for contraceptive counseling occurring via telehealth was low (<1%) in 2019, increased to 34% in April 2020, and decreased to 9-12% in June-September 2020.

CONCLUSIONS

Substantial changes in commercial insurance claims for contraceptive services occurred during the beginning of the COVID-19 pandemic, including transient decreases in IUD and implant claims and increases in telehealth contraceptive counseling claims. Contraceptive claims data can be used by decision makers to identify service gaps and evaluate use of interventions like telehealth to improve contraceptive access, including during public health emergencies.

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

PURPOSE

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

METHODS

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

RESULTS

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

DISCUSSION

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

Adapting a Counseling-Plus-mHealth Intervention for the Virtual Environment to Reduce Sexual and Reproductive Health Risk Among Young Women with Depression

MARSSI (Momentary Affect Regulation - Safer Sex Intervention) is a counseling-plus-mobile health (mhealth) intervention to reduce sexual and reproductive health (SRH) risks for women with depression and high-risk sexual behavior. Due to the COVID-19 pandemic limiting in-person care, we sought to develop the counseling and mhealth app onboarding for virtual implementation. A team with SRH, adolescent medicine, motivational interviewing, cognitive behavioral therapy, and technology expertise adapted the counseling through an iterative consensus process. We identified essential aspects of the counseling, specified the content so the counseling could be delivered in person or virtually with fidelity, and considered best practices for telehealth for the focus population. Virtual counseling retained key elements from in-person counseling while including enhancements with engaging visual and audio-video aids. Instructions and programming were developed to support virtual counseling delivery and onboarding for the mhealth app component of MARSSI. After testing the virtual format in mock sessions, we implemented a small-scale feasibility study in an adolescent medicine clinic with women with depressive symptoms and high-risk sexual behavior age 18-24 years (N = 9). Participants experienced minimal technical difficulties and expressed satisfaction with the virtual format, and all were able to complete app onboarding successfully. Expanding delivery options for SRH interventions to include virtual can improve access, particularly for populations with psychological and environmental barriers to care.

Comparison of interpersonal quality of contraceptive counseling delivered via telehealth versus in person

OBJECTIVES

This study aimed to compare the interpersonal quality of contraceptive counseling between telehealth and in-person visits.

STUDY DESIGN

Patients at a single Title X-funded clinic selected their preferred counseling modality (in person or telehealth via video or telephone) when scheduling an appointment for contraception. After counseling, we invited patients to complete a survey and recorded their desired contraceptive method. We assessed the quality of counseling using the Interpersonal Quality in Family Planning scale. We reviewed the electronic medical record to identify any subsequent clinician visit. We performed between-group comparisons using Mann-Whitney U, χ2, and Fisher exact tests.

RESULTS

From March 2021 to June 2022, 360 patients were eligible to participate, and 296 (82%) completed the survey and were included in the analysis; 150 (51%) completed counseling in person, and 146 (49%) completed counseling via telehealth. In the telehealth group, 102 (70%) chose telephone, and 44 (30%) chose video. Respondent characteristics were similar between groups. The majority of respondents in both groups reported high quality of counseling, defined as a top score on the Interpersonal Quality in Family Planning scale (75.0% telehealth respondents and 80.0% in person, p = 0.30). Compared to respondents completing in-person counseling, telehealth respondents were less likely to have a subsequent clinician visit (89.0% versus 100.0%, p < 0.001).

CONCLUSIONS

The majority of respondents reported high-quality contraceptive counseling without significant difference between the modalities. However, respondents choosing telehealth were less likely to have a subsequent clinician visit. Given the higher uptake of telephone compared to video, telehealth via telephone may be more accessible or acceptable to some patients.

IMPLICATIONS

Contraceptive counseling via telehealth has similar high interpersonal quality when compared to traditional, in-person visits. However, barriers may exist for patients who choose telehealth contraceptive counseling to access subsequent in-person care. Utilization of telehealth for contraceptive visits may provide opportunities for more equitable health care and to expand contraceptive access.

Prevalence of Abortions Prior to and During the COVID-19 Pandemic in a Large Health Care System

INTRODUCTION

The coronavirus disease 2019 (COVID-19) pandemic presented patients with numerous barriers to accessing health care, including access to reproductive health services. The goal of this study was to assess the prevalence of abortion prior to versus during the COVID-19 pandemic within a large health care system to better understand if patients were able to access abortion care.

METHODS

This was a retrospective, data-only cohort study examining the prevalence of abortion among patients aged 15 to 44 within Kaiser Permanente Northern California (KPNC) in the first 6 months of the COVID-19 stay-at-home order (April 1 to September 30, 2020) compared with a 6-month period in the year prior to the COVID-19 pandemic (April 1 to September 30, 2019). Analyses were conducted using χ2 and t tests, with a P value < .05 considered statistically significant.

RESULTS

The prevalence of abortion among patients at risk of pregnancy in 2019 and 2020 was identical, at 0.04% (P = .93). Baseline characteristics were similar between the 2 periods. The prevalence of smoking among patients who had an abortion in 2019 was 11.24%, compared with 9.04% in 2020 (P = .0009). Additionally, 85.80% of patients had KPNC insurance 6 months after the abortion in 2019, compared with 89.53% in 2020 (P < .0001).

DISCUSSION

The prevalence of abortion remained similar prior to and during the first 6 months of the COVID-19 pandemic within KPNC. Patients seeking abortion were less likely to smoke and were more likely to have consistent insurance 6 months after their abortion in 2020 versus 2019, potentially suggesting the COVID-19 pandemic resulted in healthier behaviors and more consistent access to health care. Despite stay-at-home orders and canceling of in-person clinic visits, abortion services remained accessible to a diverse population within a large health care system.

Effects of the COVID-19 pandemic on publicly supported clinics providing contraceptive services in four US states

Objectives

The COVID-19 pandemic has disrupted contraceptive service provision in the United States (US). We aimed to explore the impact of COVID-19 on the publicly supported family planning network at the provider level. This study adds to the literature documenting the challenges of the pandemic as well as how telehealth provision compares across timepoints.

Study design

We conducted a survey among sexual and reproductive health (SRH) providers at 96 publicly supported clinics in four US states asking about two timepoints-one early in the pandemic and one later in the pandemic. We used descriptive statistics to summarize the data.

Results

We found that almost one-third of sites reduced contraceptive services because of the pandemic, with a few temporarily stopping contraceptive services altogether. More sites stopped provision of long-acting reversible contraception (LARC), Pap tests, and Human papillomavirus (HPV) vaccinations than other methods or services. We also found that sites expanded some practices to make them more accessible to patients, such as extending existing contraceptive prescriptions without consultations for established patients and expanding telehealth visits for contraceptive counseling. In addition, sites reported high utilization of telehealth to provide contraceptive services.

Conclusions

Understanding how service delivery changed due to the pandemic and how telehealth can be used to provide SRH services sheds light on how these networks can best support providers and patients in the face of unprecedented crises such as the COVID-19 pandemic.

Implications

This study demonstrates that providers increased provision of telehealth for sexual and reproductive health care during the COVID-19 pandemic; policymakers in the US should support continued reimbursement of telehealth care as well as resources to expand telehealth infrastructure. In addition, this study highlights the need for more research on telehealth quality.

Contraceptive care in the United States during the COVID-19 pandemic: A social media survey of contraceptive access, telehealth use and telehealth quality

OBJECTIVES

To examine demographic, socioeconomic, and regional differences in contraceptive access, differences between telehealth and in-person contraception visits, and telehealth quality in the United States during the COVID-19 pandemic.

STUDY DESIGN

We surveyed reproductive-age women about contraception visits during the COVID-19 pandemic via social media in July 2020 and January 2021. We used multivariable regression to examine relationships between age, racial/ethnic identity, educational attainment, income, insurance type, region, and COVID-19 related hardship, and ability to obtain a contraceptive appointment, telehealth vs in-person visits, and telehealth quality scores.

RESULTS

Among 2031 respondents seeking a contraception visit, 1490 (73.4%) reported any visit, of which 530 (35.6%) were telehealth. In adjusted analyses, lower odds of any visit was associated with Hispanic/Latinx and Mixed race/Other identity (aOR 0.59 [0.37-0.94], aOR 0.36 [0.22-0.59], respectively), the South, Midwest, Northeast (aOR 0.63 [0.47-0.85], aOR 0.64 [0.46-0.90], aOR 0.52 [CI 0.36-0.75], respectively), no insurance (aOR 0.63 [0.43-0.91]), greater COVID-19 hardship (aOR 0.52 [0.31-0.87]), and earlier pandemic timing (January 2021 vs July 2020 aOR 2.14 [1.69-2.70]). Respondents from the Midwest and South had lower odds of telehealth vs in-person care (aOR 0.63 [0.44-0.88], aOR 0.54 [0.40-0.72], respectively). Hispanic/Latinx respondents and those in the Midwest had lower odds of high telehealth quality (aOR 0.37 [0.17-0.80], aOR 0.58 [0.35-0.95], respectively).

CONCLUSIONS

We found inequities in contraceptive care access, less telehealth use for contraception visits in the South and Midwest, and lower telehealth quality among Hispanic/Latinx people during the COVID-19 pandemic. Future research should focus on telehealth access, quality, and patients' preferences.

IMPLICATIONS

Historically marginalized groups have faced disproportionate barriers to contraceptive care, and telehealth for contraceptive care has not been employed equitably during the COVID-19 pandemic. Though telehealth has the potential to improve access to care, inequitable implementation could exacerbate existing disparities.

Remote Provision of Medication Abortion and Contraception Through Telemedicine

This Narrative Review describes the remote provision of family planning services, including medication abortion and contraception, through telemedicine. The coronavirus disease 2019 (COVID-19) pandemic was a catalyst to shift toward telemedicine to maintain and expand access to crucial reproductive health services when public health measures necessitated social distancing. There are legal and political considerations when providing medication abortion through telemedicine, along with unique challenges, even more so after the Dobbs decision starkly limited options for much of the country. This review includes the literature describing the logistics of telemedicine and modes of delivery for medication abortion and details special considerations for contraceptive counseling. Health care professionals should feel empowered to adopt telemedicine practices to provide family planning services to their patients.

Contraceptive Access and Use Among Undergraduate and Graduate Students During COVID-19: Online Survey Study

BACKGROUND

The COVID-19 pandemic led to widespread college campus closures in the months of March to June 2020, endangering students' access to on-campus health resources, including reproductive health services.

OBJECTIVE

To assess contraceptive access and use among undergraduate and graduate students in North Carolina during the COVID-19 pandemic.

METHODS

We conducted a cross-sectional web-based survey of undergraduate and graduate students enrolled at degree-granting institutions in North Carolina. Participants were recruited using targeted Instagram advertisements. The survey queried several aspects of participants' sexual behavior, including sex drive, level of sexual experience, number of sexual partners, digital sexual experience, dating patterns, and types of contraception used. Participants were asked to compare many of these behaviors before and after the pandemic. The survey also assessed several sociodemographic factors that we hypothesized would be associated with contraceptive use based on prior data, including educational background, sexual orientation and gender minority status (ie, lesbian, gay, bisexual, transgender, queer), health insurance status, race, ethnicity, degree of sensation seeking, religiosity, and desire to become pregnant.

RESULTS

Over 10 days, 2035 Instagram users began our survey, of whom 1002 met eligibility criteria. Of these 1002 eligible participants, 934 completed the survey, for a 93% completion rate. Our respondents were mostly female (665/934, 71%), cisgender (877/934, 94%), heterosexual (592/934, 64%), white (695/934 75%), not Hispanic (835/934, 89%), and enrolled at a 4-year college (618/934, 66%). Over 95% (895/934) of respondents reported that they maintained access to their preferred contraception during the COVID-19 pandemic. In a multivariable analysis, participants who were enrolled in a 4-year college or graduate program were less likely to lose contraceptive access when compared to participants enrolled in a 2-year college (risk ratio [RR] 0.34, 95% CI 0.16-0.71); in addition, when compared to cisgender participants, nonbinary and transgender participants were more likely to lose contraceptive access (RR 2.43, 95% CI 1.01-5.87). Respondents reported that they were more interested in using telehealth to access contraception during the pandemic. The contraceptive methods most commonly used by our participants were, in order, condoms (331/934, 35.4%), oral contraception (303/934, 32.4%), and long-acting reversible contraception (LARC; 221/934, 23.7%). The rate of LARC use among our participants was higher than the national average for this age group (14%). Emergency contraception was uncommonly used (25/934, 2.7%).

CONCLUSIONS

Undergraduate and graduate students in North Carolina overwhelmingly reported that they maintained access to their preferred contraceptive methods during the COVID-19 pandemic and through changing patterns of health care access, including telehealth. Gender nonbinary and transgender students and 2-year college students may have been at greater risk of losing access to contraception during the first year of the COVID-19 pandemic.

Adapting Family Planning Service Delivery in Title X and School-Based Settings during COVID-19: Provider and Staff Experiences

The COVID-19 pandemic introduced urgent and unique challenges to family planning providers and staff in ensuring continued access to high-quality services, particularly for groups who experience greater barriers to accessing services, such as women with systemically marginalized identities and adolescents and young adults (AYA). While research has documented key adaptations made to service delivery during the early phase of the pandemic, limited studies have used qualitative methods. This paper draws on qualitative interview data from family planning providers and staff in Title-X-funded clinics and school-based clinics-two settings that serve populations that experience greater barriers to accessing care-to (a) describe the adaptations made to service delivery during the first year of the pandemic and (b) explore provider and staff experiences and impressions implementing these adaptations. In-depth interviews were conducted with 75 providers and staff between February 2020 and February 2021. Verbatim transcripts were analyzed via inductive content analysis followed by thematic analysis. Four key themes were identified: (1) Title-X- and school-based staff made multiple, concurrent adaptations to continue family planning services; (2) providers embraced flexibility for patient-centered care; (3) school-based staff faced unique challenges to reaching and serving youth; and (4) COVID-19 created key opportunities for innovation. The findings suggest several lasting changes to family planning service delivery and provider mindsets at clinics serving populations hardest hit by the pandemic. Future studies should evaluate promising practices in family planning service delivery-including telehealth and streamlined administrative procedures-and explore how these are experienced by diverse patient populations, particularly AYA and those in areas where privacy or internet access are limited.

Perceptions and attitudes of patients and healthcare workers towards the use of telemedicine in Botswana: An exploratory study

INTRODUCTION

In March 2020, the Botswana Ministry of Health and Wellness approved a National eHealth Strategy. Although a milestone, the strategy does not mention telemedicine. There is need to address this by developing an evidence-based adjunct strategy for telemedicine to facilitate its introduction and adoption. To do so, several stages of a published eHealth Strategy Development Framework were mimicked. This allowed situational awareness to be created through exploring behavioural factors and perceptions that might influence the adoption of telemedicine in Botswana. The study aim was to explore current issues, concerns, perceptions, attitudes, views, and knowledge of patients and healthcare professionals regarding health-related issues and telemedicine that might influence implementation of telemedicine in Botswana and thereby inform future development of a telemedicine strategy.

METHODS

An exploratory survey study was conducted using different survey questionnaires for patients and healthcare professionals, each using a mix of open- and closed-ended questions. These questionnaires were administered to convenience samples of healthcare professionals and patients at 12 public healthcare facilities in Botswana; seven clinics (three rural; four urban), and five hospitals (two primary, two district, and one tertiary), selected to align with the country's decentralised healthcare structure.

RESULTS

Fifty-three healthcare professionals and 89 patients participated. Few healthcare professionals had actively used telemedicine for clinical consults and self-education using telephone calls, cell phone apps, or video conferencing (doctors 42%, nurses 10%). Only a few health facilities had telemedicine installations. Healthcare professional preference for future telemedicine uses were e-learning (98%), clinical services (92%), and health informatics (electronic records (87%). All healthcare professionals (100%) and most patients (94%) were willing to use and participate in telemedicine programmes. Open-ended responses showed additional perspective. Resource shortages (health human resources and infrastructure) were key to both groups. Convenience, cost effectiveness, and increased remote patient access to specialists were identified as enablers to telemedicine use. However inhibitors were cultural and traditional beliefs, although privacy, security and confidentiality were also identified. Results were consistent with findings from other developing countries.

CONCLUSION

Although use, knowledge, and awareness of telemedicine are low, general acceptance, willingness to use, and understanding of benefits are high. These findings bode well for development of a telemedicine-specific strategy for Botswana, complementary to the National eHealth Strategy, to guide more systematic adoption and application of telemedicine in the future.

Is the COVID-19 Pandemic Continuing to Impact Sexual and Reproductive Health Services for Adolescents? Findings From a 2021 Survey of US Physicians

PURPOSE

We examined the impact of the COVID-19 pandemic in Fall 2021 on sexual and reproductive health (SRH) services among physicians whose practice provided these services to adolescents just before the pandemic.

METHODS

Data were from the DocStyles online panel survey administered September-November 2021 to US physicians who reported their practice provided SRH services to adolescent patients before the pandemic (n = 948). We calculated prevalence of service delivery challenges (e.g., limited long-acting reversible contraception services) and use of strategies to support access (e.g., telehealth) in the month prior to survey completion, compared these estimates with prevalence "at any point during the COVID-19 pandemic", and examined differences by physician specialty and adolescent patient volume.

RESULTS

Fewer physicians reported their practice experienced service delivery challenges in the month prior to survey completion than at any point during the pandemic. About 10% indicated limited long-acting reversible contraception and sexually transmitted infection testing services in the prior month overall; prevalence varied by physician specialty (e.g., 26% and 17%, respectively by service, among internists). Overall, about 25% of physicians reported reductions in walk-in hours, weekend/evening hours, and adolescents seeking care in the prior month. While most practices that initiated strategies supporting access to services during the pandemic used such strategies in the prior month, some practices (22%-37% depending on the strategy) did not.

DISCUSSION

Findings suggest some physicians who serve adolescents continued to experience challenges providing SRH services in the Fall 2021, and some discontinued strategies to support access that had been initiated during the pandemic.

Telemedicine for Adolescent and Young Adult Long-Acting Reversible Contraception Follow-Up Care amidst a Global Pandemic

STUDY OBJECTIVE

To describe adolescent and young adult (AYA) long-acting reversible contraception (LARC) follow-up care via telemedicine in the year following the COVID-19 pandemic onset DESIGN: Longitudinal cohort study SETTING: Three academic adolescent medicine clinics in the United States PARTICIPANTS: AYAs using LARC INTERVENTIONS: None MAIN OUTCOME MEASURES: The main outcome measures were patient characteristics, visit information (frequency, timing, and modality), patient-reported symptoms, and outcomes for those presenting for LARC follow-up care between April 1, 2020, and March 31, 2021. Descriptive statistics were used to describe the sample. χ² tests and t tests were used to compare groups. Adjusted logistic regression models using general estimating equations were applied to assess factors associated with telemedicine visits and to examine visit outcomes.

RESULTS

Of the 319 AYAs (ages 13.6-25.7 years), 40.1% attended at least one LARC telemedicine visit. Patients attending any telemedicine encounter vs only in-person visits had similar demographic and clinical characteristics. Of the 426 follow-up visits, 270 (63.4%) were conducted in person and 156 (36.6%) were performed via telemedicine. Most visits (62.7%) occurred within 12 months of device insertion. Reports of bothersome uterine bleeding beyond patient expectations (OR = 1.26; 95% CI, 0.80-1.96), any symptom (OR = 1.40; 95% CI, 0.94-2.10), or 2 or more symptoms (OR = 1.22; 95% CI, 0.67-2.22) at follow-up was not associated, positively or negatively, with mode of follow-up. Management of bleeding (OR = 1.27; 95% CI, 0.56-2.89), management of acne (P = .46), and need for rapid follow-up (P = .33) were similar between follow-up modalities.

CONCLUSIONS

Patient demographic/clinical characteristics and visit outcomes were similar between telemedicine and in-person LARC follow-up. Telemedicine could play an important role in AYA LARC care.

Perceived Access to Contraception via Telemedicine Among Young Adults: Inequities by Food and Housing Insecurity

BACKGROUND

Telemedicine expanded rapidly during the COVID-19 pandemic, including for contraceptive services. Data are needed to understand whether young people can access telemedicine for contraception, especially in underserved populations.

OBJECTIVE

To compare young people's perceived access to telemedicine visits for contraception during the COVID-19 pandemic by food and housing insecurity.

DESIGN

Supplementary study to a cluster randomized controlled trial in 25 community colleges in California and Texas. Online surveys were administered May 2020 to April 2021. Mixed-effects logistic regression models with random effects for site were used to examine differences in access to contraception through telemedicine by food and housing insecurity status, controlling for key sociodemographic characteristics, including race/ethnicity, non-English primary language, health insurance status, and state of residence, and contraceptive method used.

PARTICIPANTS

1,414 individuals assigned female at birth aged 18-28.

MAIN MEASURES

Survey measures were used to capture how difficult it would be for a participant to have a telemedicine visit (phone or video) for contraception.

KEY RESULTS

Twenty-nine percent of participants were food insecure, and 15% were housing insecure. Nearly a quarter (24%) stated that it would be difficult to have a phone or video visit for contraception. After accounting for sociodemographic factors and type of method used, food insecure (adjusted odds ratio [aOR], 2.17; 95% confidence interval [CI], 1.62-2.91) and housing insecure (aOR, 1.62; 95% CI, 1.13-2.33) participants were significantly more likely to report that it would be difficult to use telemedicine for contraception during the pandemic.

CONCLUSIONS

Underserved patients are those who could benefit most from the expansion of telemedicine services, yet our findings show that young people experiencing basic needs insecurity perceive the greatest difficulty accessing these services for essential reproductive care.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03519685.

Telehealth for Women's Preventive Services for Reproductive Health and Intimate Partner Violence: a Comparative Effectiveness Review

BACKGROUND

Telehealth delivery of preventive health services may improve access to care; however, its effectiveness and adverse effects are unknown. We conducted a comparative effectiveness review on the effectiveness and harms of telehealth interventions for women's reproductive health and intimate partner violence (IPV) services.

METHODS

We searched MEDLINE, Cochrane Library, CINAHL, and Scopus for English-language studies (July 2016 to May 2022) for randomized controlled trials (RCTs) and observational studies of telehealth strategies for women's reproductive health and IPV versus usual care. Two investigators identified studies and abstracted data using a predefined protocol. Study quality was assessed using study design-specific standardized methods; disagreements were resolved through consensus.

RESULTS

Eight RCTs, 1 nonrandomized trial, and 7 observational studies (n=10 731) were included (7 studies of contraceptive care and 9 of IPV services). Telehealth interventions to supplement contraceptive care demonstrated similar rates as usual care for contraceptive use, sexually transmitted infections, and pregnancy (low strength of evidence [SOE]); evidence on abortion was insufficient. Outcomes were also similar between telehealth interventions to replace or supplement IPV services and comparators for repeat IPV, depression, posttraumatic stress disorder, fear of partner, coercive control, self-efficacy, and safety behaviors (low SOE). In these studies, telehealth barriers included limited internet access, digital literacy, technical challenges, and confidentiality concerns. Strategies to ensure safety increased telehealth use for IPV services. Evidence on access, health equity, or harms was lacking.

DISCUSSION

Telehealth interventions for contraceptive care and IPV services demonstrate equivalent clinical and patient-reported outcomes versus in-person care, although few studies are available. Effective approaches for delivering these services and how to best mobilize telehealth, particularly for women facing barriers to care remain uncertain.

TRIAL REGISTRATION

PROSPERO CRD42021282298.

Client experiences with telehealth using LINE for consultation and assessment of adverse effects of contraceptive implants during the COVID-19 pandemic in Thailand

Objective

This study aimed to examine clients' experiences with telehealth use for contraceptive implant consultation.

Methods

An online, self-administered survey was conducted with women who used contraceptive implants and faced adverse effects, inquired about side effects, or had concerns. Clients received consultations via LINE, which is a free chat application widely used in Thailand. Participants completed a questionnaire regarding their experiences and satisfaction within 7 days after using the service and a follow-up questionnaire to inquire about the need for in-person services 30 days after using the service.

Results

The participants were 200 women, with a response rate of 82%. Overall, 94% of participants were satisfied with the consultation. Moreover, 37.5% received a message response within 6 hours, and most (89.5%) got a response within 24 hours. The three most frequently reported symptoms were abnormal bleeding or spotting, mood swings, and itching or pain at the surgical site. Most adverse effects were managed through online consultation. Approximately one-third of the participants required in-person visits 30 days after telehealth consultation.

Conclusions

Telehealth consultation for contraceptive implant follow-up resulted in high client satisfaction. Most adverse effects could be managed using telehealth services. Therefore, telehealth could ensure sustained accessibility to reproductive healthcare during and post-COVID-19.

A Content Analysis of Reddit Users' Posts about Challenges to Contraceptive care-seeking during COVID-19-related Restrictions in the United States

The COVID-19 pandemic in the United States caused disruptions in care seeking and delivery during the spring of 2020, including for contraceptive care. We examined how some individuals experienced and responded to barriers to accessing contraceptive care by conducting a content analysis of relevant Reddit posts. We collected 2666 posts by scraping relevant subreddits from February 1, 2020, to April 15, 2020, and filtering by selected keywords. Among the 101 posts on contraception and the COVID-19 pandemic, we explored three main themes: barriers to accessing general healthcare during the early pandemic, problems and concerns specific to contraceptive use, and attempts to navigate the obstacles to contraceptive care or use-related concerns. The Reddit posts demonstrated the disruptive force the early pandemic had on contraceptive care and provided a unique window into the concerns posters expressed on Reddit during this time. Many posters asked questions related to accessing contraception and side effects and sought reassurance from these online forums. Our results suggest that there were barriers to accessing reliable, high-quality, and evidence-based information about contraception during this disruption in care. The findings also underscore that conversational and interactive means of seeking out information are important modes for learning about and discussing contraception for some and may be especially helpful during clinic closures and other restrictions on access.

Impact of the COVID-19 pandemic on access to and utilisation of services for sexual and reproductive health: a scoping review

INTRODUCTION

The COVID-19 pandemic has negatively impacted health systems globally and widened preexisting disparities. We conducted a scoping review on the impact of the COVID-19 pandemic on women and girls' access to and utilisation of sexual and reproductive health (SRH) services for contraception, abortion, gender-based and intimate partner violence (GBV/IPV) and sexually transmitted infections (STIs).

METHODS

We systematically searched peer reviewed literature and quantitative reports, published between December 2019 and July 2021, focused on women and girls' (15-49 years old) access to and utilisation of selected SRH services during the COVID-19 pandemic. Included studies were grouped based on setting, SRH service area, study design, population and reported impact. Qualitative data were coded, organised thematically and grouped by major findings.

RESULTS

We included 83 of 3067 identified studies and found that access to contraception, in-person safe abortion services, in-person services for GBV/IPV and STI/HIV testing, prevention and treatment decreased. The geographical distribution of this body of research was uneven and significantly less representative of countries where COVID-19 restrictions were very strict. Access was limited by demand and supply side barriers including transportation disruptions, financial hardships, limited resources and legal restrictions. Few studies focused on marginalised groups with distinct SRH needs.

CONCLUSION

Reports indicated negative impacts on access to and utilisation of SRH services globally, especially for marginalised populations during the pandemic. Our findings call for strengthening of health systems preparedness and resilience to safeguard global access to essential SRH services in ongoing and future emergencies.

"This has definitely opened the doors": Provider perceptions of patient experiences with telemedicine for contraception in Illinois

CONTEXT

The COVID-19 pandemic increased the provision of contraception through telemedicine. This qualitative study describes provider perceptions of how telemedicine provision of contraception has impacted patient care.

METHODS

We interviewed 40 obstetrics-gynecology and family medicine physicians, midwives, nurse practitioners, and support staff providing contraception via telemedicine in practices across Illinois, including Planned Parenthood of Illinois (PPIL) health centers. We analyzed interview content to identify themes around the perceived impact of telemedicine implementation on contraception access, contraceptive counseling, patient privacy, and provision of long-acting reversible contraception (LARC).

RESULTS

Participants perceived that telemedicine implementation improved care by increasing contraception access, increasing focus on counseling while reducing bias, and allowing easier method switching. Participants thought disparities in telemedicine usage and limitations to the technological interface presented barriers to patient care. Participants' perceptions of how telemedicine implementation impacts patient privacy and LARC provision were mixed. Some participants found telemedicine implementation enhanced privacy, while others felt unable to ensure privacy in a virtual space. Participants found telemedicine modalities useful for counseling patients considering methods of LARC, but they sometimes presented an unnecessary extra step for those sure about receiving one at a practice offering same day insertion.

CONCLUSION

Providers felt telemedicine provision of contraception positively impacted patient care. Improvements to counseling and easier access to method switching suggest that telemedicine implementation may help reduce contraceptive coercion. Our findings highlight the need to integrate LARC care with telemedicine workflows, improve patient privacy protections, and promote equitable access to all telemedicine modalities.

Contraceptive care service provision via telehealth early in the COVID-19 pandemic at rural and urban federally qualified health centers in 2 southeastern states

PURPOSE

To investigate telehealth use for contraceptive service provision among rural and urban federally qualified health centers (FQHCs) in Alabama (AL) and South Carolina (SC) during the initial months of the COVID-19 pandemic.

METHODS

This is a mixed-methods study using data from the FQHC Contraceptive Care Survey and key informant interviews with FQHC staff in AL and SC conducted in 2020. Differences between rural and urban clinics in telehealth use for contraceptive service provision were assessed with a chi-square test of independence. Interviews were audio recorded, transcribed, and coded to identify facilitators and barriers to telehealth.

FINDINGS

Telehealth for contraceptive care increased during the early months of the pandemic relative to prepandemic. Fewer rural clinics than urban clinics provided telehealth for contraceptive counseling (16.3% vs 50.6%) (P = .0002), emergency contraception (0.0% vs 16.1%) (P = .004), and sexually transmitted infection care (16.3% vs 34.6%) (P = .031). Key facilitators of telehealth were reimbursement policy, electronic infrastructure and technology, and funding for technology. Barriers included challenges with funding for telehealth, limited electronic infrastructure, and reduced staffing capacity.

CONCLUSIONS

Differences in telehealth service provision for contraceptive care between rural and urban FQHCs highlight the need for supportive strategies to increase access to care for low-income rural populations, particularly in AL and SC. It is essential for public and private entities to support the implementation and continuation of telehealth among rural clinics, particularly, investing in widespread and clinic-level electronic infrastructure and technology for telehealth, such as broadband and electronic health record systems compatible with telehealth technology.

The impact of coronavirus on reproduction: contraceptive access, pregnancy rates, pregnancy delay, and the role of vaccination

It is important to closely examine trends in reproduction during a pandemic because it provides not only the foundation for an improved future response but also crucial insights regarding the disparate impact across different races and socioeconomic classes. The coronavirus disease 2019 pandemic is a prime example of the impact a pandemic can have on a nation’s reproductive health. Contraception and abortion access became more difficult with more barriers to access, likely contributing to increasing unintended pregnancy rates. Underrepresented minorities and vulnerable populations were disproportionately affected by the virus on their reproductive health as well as by the virus itself. As the first ever messenger ribonucleic acid vaccine in conjunction with the lack of inclusion of pregnant and peripartum women in initial studies and conflicting and misinformation on social media, the initial role of the coronavirus disease 2019 vaccine in women of reproductive age was unclear. Further research inclusive of this group of women has led to the consensus by major medical societies to recommend vaccination of women regardless of pregnancy or lactating status.

Examining these topics in depth will lead to the development of strategies that can be employed to mitigate the negative effects on reproductive health during the current pandemic and can also be applied to future strategic plans to prevent similar negative outcomes.

Telehealth for Contraceptive Services During the COVID-19 Pandemic: Provider Perspectives

Background

Telehealth use rapidly increased during the COVID-19 pandemic, including for contraceptive care (e.g., counseling and method provision). This study explored providers’ experiences with contraceptive care via telehealth.

Methods

We conducted a survey with open-ended responses among contraceptive providers across the United States. The study population included physicians, nurse practitioners, health educators, and other health professionals (n = 546). Data were collected from April 10, 2020, to January 29, 2021. We conducted qualitative content analysis of the open-ended responses.

Results

Providers highlighted the benefits of telehealth, including continuing access to contraceptive services and accommodating patients who faced challenges attending in-person contraceptive visits. Providers at school-based health centers reported telehealth allowed them to reach young people while schools were closed. However, many providers noted a lack of patient awareness about the availability of telehealth services and disparities in access to technology. Providers felt there was less personal connection in virtual contraceptive counseling, noted challenges with confidentiality, and expressed concern about the inability to provide the full range of contraceptive methods through telehealth alone.

Conclusions

The pandemic significantly impacted contraceptive health care delivery. Telehealth has sustained access to contraception in important ways, but has been accompanied by various challenges, including technological access and confidentiality. As hybrid models of care evolve, it is important to assess how telehealth can play a role in providing contraceptive care while addressing its barriers.

Effective interventions to ensure MCH (Maternal and Child Health) services during pandemic related health emergencies (Zika, Ebola, and COVID-19): A systematic review

INTRODUCTION

Ensuring accessible and quality health care for women and children is an existing challenge, which is further exacerbated during pandemics. There is a knowledge gap about the effect of pandemics on maternal, newborn, and child well-being. This systematic review was conducted to study maternal and child health (MCH) services utilization during pandemics (Zika, Ebola, and COVID-19) and the effectiveness of various interventions undertaken for ensuring utilization of MCH services.

METHODOLOGY

A systematic and comprehensive search was conducted in MEDLINE/PubMed, Cochrane CENTRAL, Embase, Epistemonikos, ScienceDirect, and Google Scholar. Of 5643 citations, 60 potential studies were finally included for analysis. The included studies were appraised using JBI Critical appraisal tools. Study selection and data extraction were done independently and in duplicate. Findings are presented narratively based on the RMNCHA framework by World Health Organization (WHO).

RESULTS

Maternal and child health services such as antenatal care (ANC) visits, institutional deliveries, immunization uptake, were greatly affected during a pandemic situation. Innovative approaches in form of health care services through virtual consultation, patient triaging, developing dedicated COVID maternity centers and maternity schools were implemented in different places for ensuring continuity of MCH care during pandemics. None of the studies reported the effectiveness of these interventions during pandemic-related health emergencies.

CONCLUSION

The findings suggest that during pandemics, MCH care utilization often gets affected. Many innovative interventions were adopted to ensure MCH services. However, they lack evidence about their effectiveness. It is critically important to implement evidence-based appropriate interventions for better MCH care utilization.

Best Practice During Teleconsultations With Adolescents: A Scoping Review

PURPOSE

Teleconsultations are increasingly used to deliver health care, yet guidance on how to maximize health outcomes and ensure the quality and rights-based principles of adolescent health care during teleconsultations is lacking. This scoping review synthesized the literature on teleconsultations with adolescents, with the objective of informing a practical guidance for healthcare professionals.

METHODS

Eight databases were searched to identify articles published between 2010 and 2020 in English, French, or Spanish that provided evidence or guidance on synchronous teleconsultations with 10- to 19-year-olds. Web sites in six high-income countries and six low- to middle-income countries were also searched and a Google search was conducted. Data were analyzed using narrative synthesis.

RESULTS

Of 59 total references, 51 were from high-income countries. References included primary research (n = 21), reviews (n = 13), clinical guidance (n = 9), case reports (n = 9), commentaries (n = 6), and a website (n = 1). Just under half (46%) were descriptive, qualitative, or expert opinion. The main focus was mental health and behavioral disorders.

DISCUSSION

Good evidence on the complexities of conducting teleconsultations with adolescents is lacking. Questions remain regarding the scope and acuity of health issues for which teleconsultations are appropriate, their role in overcoming or contributing to inequalities, and the practicalities of conducting consultations.

Assessing differences in contraceptive provision through telemedicine among reproductive health providers during the COVID-19 pandemic in the United States

Background

Providers faced challenges in maintaining patient access to contraceptive services and public health safety during the COVID-19 pandemic. Due to increased barriers to care, providers increasingly used telemedicine for contraceptive care, curbside services, mail-order pharmacies, and on-line or home delivery of contraceptive methods, including self-administration of subcutaneous depo medroxyprogesterone acetate (DMPA-SQ). To better understand how reproductive health providers adapted service provision during the pandemic, this study assessed clinical practice changes and strategies providers adopted throughout the United States to maintain contraceptive care, particularly when clinics closed on-site, and the challenges that remained in offering contraceptive services, especially to marginalized patient populations.

Methods

We surveyed U.S. providers and clinic staff (n = 907) in April 2020–January 2021, collecting data on contraceptive service delivery challenges and adaptations, including telemedicine. We assessed clinical practice changes with multivariate regression analyses using generalized linear models with a Poisson distribution and cluster robust standard errors, adjusting for clinic patient volume, practice setting, region, Title X funding, and time of survey.

Results

While 80% of providers reported their clinic remained open, 20% were closed on-site. Providers said the pandemic made it more difficult to offer the full range of contraceptive methods (65%), contraceptive counseling (61%) or to meet the needs of patients in marginalized communities (50%). While only 11% of providers offered telemedicine pre-pandemic, most offered telemedicine visits (79%) during the pandemic. Some used mail-order pharmacies (35%), curbside contraceptive services (22%), and DMPA-SQ for self-administration (10%). Clinics that closed on-site were more likely to use mail-order pharmacies (aRR 1.83, 95% CI [1.37–2.44]) and prescribe self-administered DMPA-SQ (aRR 3.85, 95% CI [2.40–6.18]). Clinics closed on-site were just as likely to use telemedicine as those that remained open. Among clinics using telemedicine, those closed on-site continued facing challenges in contraceptive service provision.

Conclusions

Clinics closing on-site were just as likely to offer telemedicine, but faced greater challenges in offering contraceptive counseling and the full range of contraceptive methods, and meeting the needs of marginalized communities. Maintaining in-person care for contraceptive services, in spite of staffing shortages and financial difficulties, is an important objective during and beyond the pandemic.

Providers faced challenges in maintaining patient access to contraceptive services and public health safety during the COVID-19 pandemic. Due to increased barriers to care, providers increasingly used telemedicine for contraceptive care as well as using curbside services, mail-order pharmacies, and on-line or home delivery of contraceptive methods, including self-administration of subcutaneous depo medroxyprogesterone acetate (DMPA-SQ). This study examined use of telemedicine and other clinical practice changes among U.S. contraceptive providers during the COVID-19 pandemic. We surveyed providers (n=907) in April 2020–January 2021, collecting data on contraceptive service delivery challenges and adaptations, including telemedicine. Our analyses showed that, in response to the pandemic, many clinics adopted telemedicine to offer contraceptive services. Furthermore, clinics that were closed on-site were just as likely to start offering telemedicine visits during the pandemic as those that remained open. Despite these adaptions, clinics still faced challenges in offering the full range of contraceptive methods, providing contraceptive counseling, and meeting the needs of patients in marginalized communities. Offering telemedicine visits during the pandemic did not reduce the challenges in offering contraceptive services. Few studies have focused on providers and the clinical practice changes they rapidly achieved to maintain contraceptive access for their patients during the pandemic. Our results highlighted that telemedicine should be considered as a complement to on-site care because of the challenges in providing full services without in-person visits. Maintaining in-person care for contraceptive services, in spite of staffing shortages and financial difficulties, is an important objective during and beyond the pandemic.

Telehealth for gynaecology outpatients during the COVID-19 pandemic: Patient and clinician experiences

Background

The COVID‐19 pandemic has necessitated alterations in provision of health care and how patients access it. Telehealth has replaced traditional face‐to‐face outpatient clinics in an unprecedented manner. This study aimed to assess overall patient and clinician satisfaction with telehealth consultations, to establish acceptability of telehealth during pandemic and non‐pandemic times, and document feedback.

Materials and Methods

A prospective observational study involving women presenting to a general gynaecology outpatient department was performed. Women who attended for consultation between 13 July and 4 September 2020 were invited to participate in a questionnaire following their telehealth appointment. Clinicians consulting in the outpatient department were invited to complete a questionnaire at the end of the eight‐week study period. Satisfaction, utility and acceptability data were obtained using visual analogue scales (VAS).

Results

Twenty‐six out of 56 (46.4%) clinicians and 124/870 (14.3%) patients completed the questionnaire. Patients who responded were older and more likely to have been born in Australia than women who did not (P = 0.0355 and P = 0.005, respectively). Overall patient satisfaction with telehealth was high (median VAS (interquartile range), 8.6 (5.6–9.8)). More women found telehealth to be acceptable during a pandemic than afterward (8.9 vs 6.6, P < 0.0001). Clinicians were less satisfied with telehealth than patients (7.1 vs 8.6, P = 0.02); however, most would be happy to continue using telehealth in non‐pandemic times (7.0 (6.2–9.8)).

Conclusion

Telehealth consultations allow provision of gynaecological care at a time when reducing risk of infection to patients and staff is paramount. Telehealth gynaecology consultations are efficient and convenient without significant detriment to patient or clinician satisfaction.

System-Level Factors Associated With Telephone and Video Visit Use: Survey of Safety-Net Clinicians During the Early Phase of the COVID-19 Pandemic

BACKGROUND

The COVID-19 pandemic prompted safety-net health care systems to rapidly implement telemedicine services with little prior experience, causing disparities in access to virtual visits. While much attention has been given to patient barriers, less is known regarding system-level factors influencing telephone versus video-visit adoption. As telemedicine remains a preferred service for patients and providers, and reimbursement parity will not continue for audio visits, health systems must evaluate how to support higher-quality video visit access.

OBJECTIVE

This study aimed to assess health system-level factors and their impact on telephone and video visit adoption to inform sustainability of telemedicine for ambulatory safety-net sites.

METHODS

We conducted a cross-sectional survey among ambulatory care clinicians at a hospital-linked ambulatory clinic network serving a diverse, publicly insured patient population between May 28 and July 14, 2020. We conducted bivariate analyses assessing health care system-level factors associated with (1) high telephone adoption (4 or more visits on average per session); and (2) video visit adoption (at least 1 video visit on average per session).

RESULTS

We collected 311 responses from 643 eligible clinicians, yielding a response rate of 48.4%. Clinician respondents (N=311) included 34.7% (n=108) primary or urgent care, 35.1% (n=109) medical, and 7.4% (n=23) surgical specialties. Our sample included 178 (57.2%) high telephone adopters and 81 (26.05%) video adopters. Among high telephone adopters, 72.2% utilized personal devices for telemedicine (vs 59.0% of low telephone adopters, P=.04). Video nonadopters requested more training in technical aspects than adopters (49.6% vs 27.2%, P<.001). Primary or urgent care had the highest proportion of high telephone adoption (84.3%, compared to 50.4% of medical and 37.5% of surgical specialties, P<.001). Medical specialties had the highest proportion of video adoption (39.1%, compared to 14.8% of primary care and 12.5% of surgical specialties, P<.001).

CONCLUSIONS

Personal device access and department specialty were major factors associated with high telephone and video visit adoption among safety-net clinicians. Desire for training was associated with lower video visit use. Secure device access, clinician technical trainings, and department-wide assessments are priorities for safety-net systems implementing telemedicine.

An exploratory study comparing the quality of contraceptive counseling provided via telemedicine versus in-person visits

OBJECTIVE

Telemedicine for contraceptive services is purported to improve contraceptive access, yet few studies assess the quality of contraceptive counseling provided remotely. We assessed the quality of contraceptive counseling during telemedicine and office visits.

STUDY DESIGN

We conducted a cross-sectional study at Cleveland Clinic Women's Health Institute to compare contraceptive counseling quality between telemedicine (synchronous video) and office visits. We identified eligible patients through ambulatory encounters with primary contraceptive management or counseling ICD-10 codes. Respondents completed a survey assessing demographics, quality of contraceptive counseling, contraceptive method choice, affinity for technology, and attitudes toward telemedicine. We used the validated Interpersonal Quality of Family Planning (IQFP) scale to assess counseling quality. We used the Wilcoxon rank sum test, Pearson's chi-square test and Fisher's exact test to compare baseline characteristics.

RESULTS

Of all eligible patients, 110/380 (29%) completed the survey. Of those who were successfully contacted by phone or mail, 110/201 (55%) completed the survey. The IQFP scores were 'high quality' for 28/52 (54%) of telemedicine-visit respondents versus 37/58 (64%) of office-visit respondents (p = 0.29). The birth control pill was the most popular method, chosen by 27/52 (52%) of telemedicine-visit respondents and 24/58 (41%) of office-visit respondents (p = 0.27). Telemedicine respondents identified ease of communication and less scheduling difficulty as factors that promote telemedicine use. Office-visit respondents identified privacy and communication concerns as factors that deter telemedicine use.

CONCLUSION

When patients self-select the encounter type, their assessment of the quality of contraceptive counseling among telemedicine and office visits is similar, with no statistically significant differences in contraceptive method chosen. Results from this single-center study support the integration of telemedicine in contraceptive service provision.

IMPLICATIONS

The quality of contraceptive counseling is similar among telemedicine and office visits. Telemedicine visits for contraceptive counseling should be routinely offered, and existing services should be expanded.

Factors related to delays in obtaining contraception among pregnancy-capable adults in New York State during the COVID-19 pandemic: The CAP study

Objectives

To investigate factors associated with delays to obtaining contraception during the COVID-19 pandemic among pregnancy-capable adults in New York State.

Study Design

We administered a cross-sectional survey in June-July 2020 to female/transgender male New York State residents aged 18–44 years (n = 1,525). This analysis focused on respondents who were not pregnant and sought contraception (n = 953). We conducted bivariate and multinomial logistic regression analyses to assess sociodemographic, social, and health characteristics, by the outcome of delays to obtaining birth control (delayed due to COVID-19, delayed due to other reasons, no delay). We also analyzed a sub-sample who reported COVID-19 as a reason for delays (n = 317) and report the frequencies of type of contraceptive methods/procedures delayed and availability of telemedicine visits.

Results

Half of respondents had no contraceptive delays, 39% reported delays due to COVID-19, and 11% reported delays due to reasons other than COVID-19. In adjusted analyses, those who missed a rent/mortgage payment during the pandemic (aOR: 2.23; CI: 1.55, 3.22), participated in a supplemental government program in 2019 (aOR: 1.88; CI: 1.36, 2.60), and themselves/household member had COVID-19 (aOR: 1.48; CI: 1.04, 2.12) were more likely to report delays to contraception due to COVID-19 (versus no delays). In the sub-sample, 63% reported available virtual contraceptive visits, 28% unavailable, and 9% not sure. The most frequently (42%) reported delays were new prescriptions for the pill, patch, or ring.

Conclusions

Reducing financial barriers that help individuals maintain their housing and living necessities, and promoting telemedicine visits, may help increase access to contraception.

Telehealth for contraceptive care: Lessons from staff and clinicians for improving implementation and sustainability in Illinois

Objective

To solicit Illinois staff and clinician perspectives on rapid implementation of telehealth for contraceptive counseling and recommendations to improve and sustain it in the long term.

Study design

Researchers recruited and interviewed clinicians (n = 20) in primary care and obstetrics/gynecology clinics across 13 health care systems in Illinois, as well as clinicians (n = 11), leadership (n = 6) and staff (n = 7) from Planned Parenthood of Illinois clinics. Guided by the Consolidated Framework for Implementation Research, we coded and analyzed interview transcripts in Dedoose with a focus on themes regarding steps to improve quality and sustainability of telehealth.

Results

Participants expressed generally positive attitudes towards telehealth, noting that it increased access to care and time for patient education. Still, many highlighted areas of implementation that needed improvement. Clinic operations were complicated by gaps in telehealth training and the logistical needs of balancing telehealth and in-person appointments. Clinics had difficulty ensuring patient awareness of telehealth as an option for care, in addition to deficiencies with the telehealth technology itself. Finally, innovative resources for telehealth patients, while existent, have not been evenly offered across clinics. This includes the use of self-injection birth control, as well as providing medical equipment such as blood pressure cuffs in community settings. Some themes reflect issues specific to contraceptive counseling while others reflect issues with telehealth implementation in general, including confusion about reimbursement.

Conclusion

Illinois contraceptive care providers and staff wish to sustain telehealth for the long term, while also recommending specific improvements to patient communications, clinic operations, and access to supportive resources.

Implications

Our study highlights considerations for clinics to optimize implementation of telehealth services for contraceptive care. Providers described the value of clear workflows to balance in-person and telehealth visits, streamlined communications platforms, targeted patient outreach, training on providing virtual contraceptive care, and creative approaches to ensuring patient access to resources.

Reproductive justice in the time of COVID-19: a systematic review of the indirect impacts of COVID-19 on sexual and reproductive health

OBJECTIVE

Despite gendered dimensions of COVID-19 becoming increasingly apparent, the impact of COVID-19 and other respiratory epidemics on women and girls' sexual and reproductive health (SRH) have yet to be synthesized. This review uses a reproductive justice framework to systematically review empirical evidence of the indirect impacts of respiratory epidemics on SRH.

METHODS

We searched MEDLINE and CINAHL for original, peer-reviewed articles related to respiratory epidemics and women and girls' SRH through May 31, 2021. Studies focusing on various SRH outcomes were included, however those exclusively examining pregnancy, perinatal-related outcomes, and gender-based violence were excluded due to previously published systematic reviews on these topics. The review consisted of title and abstract screening, full-text screening, and data abstraction.

RESULTS

Twenty-four studies met all eligibility criteria. These studies emphasized that COVID-19 resulted in service disruptions that effected access to abortion, contraceptives, HIV/STI testing, and changes in sexual behaviors, menstruation, and pregnancy intentions.

CONCLUSIONS

These findings highlight the need to enact policies that ensure equitable, timely access to quality SRH services for women and girls, despite quarantine and distancing policies. Research gaps include understanding how COVID-19 disruptions in SRH service provision, access and/or utilization have impacted underserved populations and those with intersectional identities, who faced SRH inequities notwithstanding an epidemic. More robust research is also needed to understand the indirect impact of COVID-19 and epidemic control measures on a wider range of SRH outcomes (e.g., menstrual disorders, fertility services, gynecologic oncology) in the long-term.

COVID-19 and family planning service delivery: Findings from a survey of U.S. physicians

Equitable access to contraception is critical for reproductive autonomy. Using cross-sectional data from the DocStyles survey administered September-October 2020 (68% response rate), we compared changes in family planning-related clinical services and healthcare delivery strategies before and during the COVID-19 pandemic and assessed service provision issues among 1063 U.S. physicians whose practice provided family planning services just before the pandemic. About one-fifth of those whose practices provided the following services or strategies just before the pandemic discontinued these services during the pandemic: long-acting reversible contraception (LARC) placement (16%); LARC removal (17%); providing or prescribing emergency contraceptive pills (ECPs) in advance (18%); and reminding patients about contraception injections or LARC removal or replacement (20%). Many practices not providing the following services or strategies just before the pandemic initiated these services during the pandemic: telehealth for contraception initiation (43%); telehealth for contraception continuation (48%); and renewing contraception prescriptions without requiring an office visit (36%). While a smaller proportion of physicians reported service provision issues in the month before survey completion than at any point during the pandemic, about one-third still reported fewer adult females seeking care (37%) and technical challenges with telehealth (32%). Discontinuation of key family planning services during the COVID-19 pandemic may limit contraception access and impede reproductive autonomy. Implementing healthcare service delivery strategies that reduce the need for in-person visits (e.g., telehealth for contraception, providing or prescribing ECPs in advance) may decrease disruptions in care. Resources exist for public health and clinical efforts to ensure contraception access during the pandemic.

The impact of disasters on contraception in OECD member countries: a scoping review

OBJECTIVES

Review evidence is lacking about how contraception is affected by severe social disruption, such as that caused by the COVID-19 pandemic. The purpose of this scoping review was to explore the impact of natural and man-made disasters on contraception in OECD member countries.

METHODS

Manual searches and systematic searches in six electronic databases were conducted with no language restrictions. All articles were screened by at least two researchers. The data were analysed thematically.

RESULTS

108 articles were included. Most focussed on the Zika virus outbreak (n = 50) and the COVID-19 pandemic (n = 28). Four key themes were identified: importance of contraception during disasters, impact of disasters on contraceptive behaviour, barriers to contraception during disasters and ways of improving use of contraception during disasters. Despite efforts to increase access to contraception including by transforming ways of delivery, barriers to use meant that unmet need persisted.

CONCLUSIONS

To prevent adverse health outcomes and reduce health costs as a result of failure to have access to contraception during disasters, there is a need to intensify efforts to remove barriers to use. This should include increasing access and information on methods of contraception and their side effects (e.g., menstrual suppression) and making contraception freely available.

Racial and ethnic differences in family planning telehealth use during the onset of the COVID-19 response in Arkansas, Kansas, Missouri, and Oklahoma

OBJECTIVES

To explore racial/ethnic disparities in family planning telehealth use.

STUDY DESIGN

We analyzed telehealth and in-clinic visits (n = 3142) from ten family planning clinics (April 1-July 31, 2020) by race/ethnicity and month.

RESULTS

Telehealth comprised 1257/3142 (40.0%) of overall visits. Telehealth was used by 242/765 (31.6%) of Black/African American and 31/106 (29.2%) multiracial patients. Patients with unknown (162/295, 54.9%), White (771/1870, 41.2%), and other (51/106, 48.1%) identities comprised the majority of telehealth visits.

CONCLUSIONS

Our study found differences in telehealth use during the COVID-19 pandemic response.

IMPLICATIONS

Understanding barriers and facilitators to telehealth is critical to reducing disparities in access.

Telemedicine for contraceptive counseling: Patient experiences during the early phase of the COVID-19 pandemic in New York City

OBJECTIVE

During theCOVID-19 pandemic, many clinicians increased provision of telemedicine services. This study describes patient experiences with telemedicine for contraceptive counseling during the COVID-19 pandemic in New York City.

STUDY DESIGN

This is a mixed-methods study which includes a web-based or phone survey and in-depth phone interviews with patients who had telemedicine visits for contraception.

RESULTS

A total of 169 patients had eligible telemedicine visits between April 1 and June 30, 2020. Of these, 86 (51%) responded to the survey, and 23 (14%) participated in the interviews. We found that 86% of survey respondents were very satisfied with the telemedicine visit, and 63% said it completely met their needs. A majority (73%) strongly agreed that these visits should be maintained after the COVID-19 pandemic, and half (51%) would be very likely to choose them over in-person visits. In-depth interviews highlighted the convenience of telemedicine, especially for those with work or parenting responsibilities. Although some patients had in-person visits after telehealth, many appreciated the counseling they received remotely, and found the subsequent in-person visits more efficient. Patients identified visits that do not require physical exams as ideal visits for telehealth, and some hoped that all or most of their future visits would be telehealth visits. Many patients (43%) expressed a preference for phone over video visits.

CONCLUSIONS

Patients reported an overall positive experience with telemedicine visits for contraceptive counseling during the COVID-19 pandemic. They appreciated the convenience of telemedicine visits and valued the virtual counseling experience.

IMPLICATIONS

Health care providers who initiated or expanded telemedicine services for contraceptive counseling during the COVID-19 pandemic should consider continuing to offer them after the pandemic. At the policy level, these findings favor expanding access to telemedicine and providing reimbursement for virtual visits, including telephone visits.