Providers' perspectives on challenges to contraceptive counseling in primary care settings

Barriers to pregnancy prevention for adolescents in rural Haiti: perceptions of healthcare providers

BACKGROUND

Little is known about healthcare providers' (HCPs) contraceptive views for adolescents in Haiti, who experience high rates of unintended pregnancy. We sought to describe HCPs' perspectives on barriers and facilitators to contraceptive care delivery in rural Haiti.

METHODS

We conducted a cross-sectional survey and qualitative interviews with HCPs in two rural communities in Haiti from 08/2021-03/2022. We assessed demographics, clinical practice behaviors and explored contraception perspectives according to Theory of Planned Behavior constructs: attitudes, subjective norms, and perceived behavioral control (e.g., people's perceptions of their ability to perform a given behavior, barriers and facilitators of a behavior).15-17 We used descriptive statistics to report proportions and responses to Likert scale and multiple-choice questions. Guided by content analysis, we analyzed interview transcripts through thematic inductive coding and team debriefing.

RESULTS

Among 58 respondents, 90% (n = 52) were female and 53% (n = 31) were nurses. Most reported always (n = 16, 28%) or very often (n = 21, 36%) obtaining a sexual history for adolescents. A majority agreed/strongly agreed that clinicians should discuss pregnancy prevention (n = 45, 78%), high-risk sexual behaviors (n = 40, 69%), and should prescribe contraception (n = 41, 71%) to adolescents. The most frequently cited provider-level barriers (i.e., significant or somewhat of a barrier) included insufficient contraception knowledge (n = 44, 77%) and time (n = 37, 64%). HCPs were concerned about barriers at the patient-level (e.g. adolescents' fear of parental notification [n = 37, 64%], adolescents will give inaccurate information about sexual behaviors [n = 25, 43%]) and system-level (e.g. resistance to providing care from administration [n = 33, 57%]). In interviews (n = 17), HCPs generally supported contraception care for adolescents. Many HCPs echoed our quantitative findings on concerns about privacy and confidentiality. HCPs reported concerns about lack of contraception education leading to misconceptions, and community and parental judgement. HCPs expressed interest in further contraception training and resources and noted the importance of providing youth-friendly contraceptive care.

CONCLUSIONS

While HCPs support contraceptive care, we identified actionable barriers to improve care for adolescents in rural Haiti. Future efforts should include increasing HCP knowledge and training, community and parent coalition building to increase contraception support and offering youth-friendly contraceptive care to offset risk for related adverse health outcomes in adolescents in rural Haiti.

Documentation of prenatal contraceptive counseling and fulfillment of permanent contraception: a retrospective cohort study

BACKGROUND

Barriers exist for the provision of surgery for permanent contraception in the postpartum period. Prenatal counseling has been associated with increased rates of fulfillment of desired postpartum contraception in general, although it is unclear if there is impact on permanent contraception specifically. Thus, we aimed to investigate the association between initial timing for prenatal documentation of a contraceptive plan for permanent contraception and fulfillment of postpartum contraception for those receiving counseling.

METHODS

This is a planned secondary analysis of a multi-site cohort study of patients with documented desire for permanent contraception at the time of delivery at four hospitals located in Alabama, California, Illinois, and Ohio over a two-year study period. Our primary exposure was initial timing of documented plan for contraception (first, second, or third trimester, or during delivery hospitalization). We used univariate and multivariable logistic regression to analyze fulfillment of permanent contraception before hospital discharge, within 42 days of delivery, and within 365 days of delivery between patients with a documented plan for permanent contraception in the first or second trimester compared to the third trimester. Covariates included insurance status, age, parity, gestational age, mode of delivery, adequacy of prenatal care, race, ethnicity, marital status, and body mass index.

RESULTS

Of the 3103 patients with a documented expressed desire for permanent contraception at the time of delivery, 2083 (69.1%) had a documented plan for postpartum permanent contraception prenatally. After adjusting for covariates, patients with initial documented plan for permanent contraception in the first or second trimester had a higher odds of fulfillment by discharge (aOR 1.57, 95% C.I 1.24-2.00), 42 days (aOR 1.51, 95% C.I 1.20-1.91), and 365 days (aOR 1.40, 95% C.I 1.11-1.75), compared to patients who had their first documented plan in the third trimester.

CONCLUSIONS

Patients who had a documented prenatal plan for permanent contraception in trimester one and two experienced higher likelihood of permanent contraception fulfillment compared to those with documentation in trimester three. Given the barriers to accessing permanent contraception, it is imperative that comprehensive, patient-centered counseling and documentation regarding future reproductive goals begin early prenatally.

Harms of third- and fourth-generation combined oral contraceptives in premenopausal women: A systematic review and meta-analysis

We assessed the available evidence regarding adverse effects on surrogate and patient-important health outcomes of third- and fourth-generation combined oral contraceptives among premenopausal women. We performed a systematic review and meta-analysis including randomized controlled trials and observational studies comparing third- and fourth-generation combined oral contraceptives with other generation contraceptives or placebo. Studies that enrolled women aged 15 to 50 years, with at least three cycles of intervention and 6 months of follow-up were included. A total of 33 studies comprising 629,783 women were included. Low-density lipoprotein cholesterol levels were significantly lower in fourth-generation oral contraceptives (mean differences (MD): -0.24 mmol/L; [95% CI -0.39 to -0.08]), while total cholesterol was significantly increased in levonorgestrel users when compared to third-generation oral contraceptives (MD: 0.27 mmol/L; [95% CI 0.04 to 0.50]). A decreased arterial thrombosis incidence was shown in fourth-generation oral contraceptive users, as compared to levonorgestrel (incidence rate ratio (IRR): 0.41; [95% CI 0.19 to 0.86]). No difference was found in the occurrence of deep venous thrombosis between fourth-generation oral contraceptives and levonorgestrel users (IRR: 0.91; [95% CI 0.66 to 1.27]; p = 0.60; I2 = 0%). Regarding the remaining outcomes, data were heterogeneous and showed no clear difference. In premenopausal women, the use of third- and fourth-generation oral contraceptives is associated with an improved lipid profile and lower risk of arterial thrombosis. Data were inconclusive regarding the rest of outcomes assessed. This review was registered in PROSPERO with CRD42020211133.

Sexual and reproductive health problems among women with mental illness attending tertiary care psychiatric outpatient clinic in India: A cross-sectional study

Objectives

Sexual and reproductive health (SRH) is a vital concern among women with mental illness (WMI) due to the increased risk for unplanned pregnancy, sexually transmitted infections (STIs), and poor obstetric outcomes. Objective of the study was to explore the current use of family planning (FP) methods, symptoms of STIs and sexual dysfunction among WMI.

Materials and Methods

This descriptive study involved 404 WMI of reproductive age (18-49 years) attending tertiary care psychiatric outpatient clinics in India. During face-to-face interviews, centers for disease control and prevention (CDC)-reproductive health assessment toolkit-FP questionnaire, STI questionnaire and Female sexual function index (FSFI) were used to collect the data.

Results

Of 404 WMI, 261(64.6%) were users, and 137 (33.9%) were non-users of FP methods. About 6(1.5%) WMI did not respond FP methods question. Female sterilization was the highest among the users, 244(93%). Among non-users, 100 (73%) were unaware of choosing the effective method of FP. Most of the WMI, 377(93.3%), were unaware of STIs. The symptoms of STI reported include unusual genital discharge 62(15.3%) and genital ulcers/ sores 58(14.4 %). Most of them, 76(63.3%), were not on any treatment. The most common reason for not taking treatment was feeling ashamed 70(92.1%). Female sexual dysfunction was reported in 176(43.6%). Most of the WMI had difficulties in the arousal domain 288(71.3%), followed by low desire 233(57.7%) and dissatisfaction 186(46%).

Conclusion

Most WMI underwent sterilization. Non-users of FP methods were not aware of choosing the effective method. Awareness about STIs was poor, and feeling ashamed was the primary reason for not availing of medical help. Nearly half of the WMI reported sexual dysfunction, among which arousal difficulties, low desire and dissatisfaction were common. Health professionals need to increase awareness about FP methods and symptoms of STIs among WMIs. Women require appropriate counselling regarding SRH and treatment for sexual dysfunction.

Optimizing Contraceptive Prescription in Smoking Women: A Quality Improvement Study

Introduction Family planning is fundamental in primary care (PC), and informed counseling helps to guide contraceptive choices. Combined hormonal contraceptives (CHC) pose cardiovascular risks, particularly when combined with smoking. According to the World Health Organization, the recommended global clinical decision is to refrain from employing CHC in female smokers aged 35 or older. This study aimed to improve contraception prescription for female smokers aged 35-54 in PC. Methods This study was conducted in a Portuguese Family Health Unit (FHU) from October 2021 to August 2022, and it followed the Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0) guidelines and the Plan-Do-Study-Act approach. Female smokers aged 35-54 were included and evaluated in three moments: baseline evaluation (October 2021), intermediate evaluation (February 2022), and post-intervention evaluation (August 2022). Interventions involved educating medical staff, creating patient awareness campaigns, and evaluating contraceptive methods. The established quality-defining goal was to decrease the prevalence of female smokers aged 35 or above using CHC to ≤5%. Results CHC prevalence among smoking women aged 35-54 decreased from 16.4% to 8.5% after nine months of the initial intervention. There was an increase in progestogen-only methods usage over time, from 25.7% to 34.0%. Discussion Despite not fully achieving the predefined goal, interventions led to a substantial reduction of CHC use among smoking women aged 35-54. Collaborative efforts between healthcare professionals and patients played a pivotal role in optimizing care and reducing cardiovascular risk. This study underscores the importance of continuous quality improvement, collaborative interventions, and knowledge updates in Family Medicine practice. While conducted in a single FHU, the intervention's multidimensional approach holds the potential for broader applicability. Conclusion In the future, healthcare teams should continue to reflect on achieved results, maintain knowledge, and empower patients in contraceptive method choices. The study contributes to improved care quality and highlights the positive impact on medical practice and patient outcomes.

Contraceptive counseling for adolescents in the emergency department: A novel curriculum for nurse practitioners and physician assistants

ABSTRACT

Many adolescents use the emergency department (ED) as their primary source of health care. As a result, the ED serves as a unique opportunity to reach adolescents. Although many adolescent visits to the ED are related to reproductive health, ED providers report barriers to providing this care, including lack of training. Nurse practitioners (NPs) and physician assistants (PAs) serve a vital role in the provision of consistent care to adolescents in the ED. The purpose of this study was to create a curriculum to train NPs and PAs at two pediatric institutions to provide patient-centered contraceptive counseling to adolescents in the pediatric ED regardless of their chief complaint. To do this, we created a four-part webinar followed by an in-person training session. Participants completed training and then conducted counseling sessions with adolescents in the ED. Counseling sessions were recorded and reviewed for fidelity to delineated counseling principles, and data from post-counseling surveys were collected. 27 NPs and PAs completed the training and conducted 99 counseling sessions. Nearly all sessions incorporated essential content and communication principles such as shared decision making (90%) and teach-back methods (75%). All NPs and PAs who participated reported satisfaction and subjective improvement in knowledge and competence from the training. This curriculum offers a novel and feasible approach to train NPs and PAs to deliver patient-centered contraception counseling to adolescents in the ED setting, and it can serve as a model for how to educate different providers to incorporate reproductive health education into the busy ED visit.

Exploring Language Used in Posts on r/birthcontrol: Case Study Using Data From Reddit Posts and Natural Language Processing to Advance Contraception Research

BACKGROUND

Contraceptive choice is central to reproductive autonomy. The internet, including social networking sites like Reddit, is an important resource for people seeking contraceptive information and support. A subreddit dedicated to contraception, r/birthcontrol, provides a platform for people to post about contraception.

OBJECTIVE

This study explored the use of r/birthcontrol, from the inception of the subreddit through the end of 2020. We describe the web-based community, identify distinctive interests and themes based upon the textual content of posts, and explore the content of posts with the most user engagement (ie, "popular" posts).

METHODS

Data were obtained from the PushShift Reddit application programming interface from the establishment of r/birthcontrol to the start date of analysis (July 21, 2011, to December 31, 2020). User interactions within the subreddit were analyzed to describe community use over time, specifically the commonality of use based on the volume of posts, the length of posts (character count), and the proportion of posts with any and each flair applied. "Popular" posts on r/birthcontrol were determined based on the number of comments and "scores," or upvotes minus downvotes; popular posts had 9 comments and a score of ≥3. Term Frequency-Inverse Document Frequency (TF-IDF) analyses were run on all posts with flairs applied, posts within each flair group, and popular posts within each flair group to characterize and compare the distinctive language used in each group.

RESULTS

There were 105,485 posts to r/birthcontrol during the study period, with the volume of posts increasing over time. Within the time frame for which flairs were available on r/birthcontrol (after February 4, 2016), users applied flairs to 78% (n=73,426) of posts. Most posts contained exclusively textual content (n=66,071, 96%), had comments (n=59,189, 86%), and had a score (n=66,071, 96%). Posts averaged 731 characters in length (median 555). "SideEffects!?" was the most frequently used flair overall (n=27,530, 40%), while "Experience" (n=719, 31%) and "SideEffects!?" (n=672, 29%) were most common among popular posts. TF-IDF analyses of all posts showed interest in contraceptive methods, menstrual experiences, timing, feelings, and unprotected sex. While TF-IDF results for posts with each flair varied, the contraceptive pill, menstrual experiences, and timing were discussed across flair groups. Among popular posts, intrauterine devices and contraceptive use experiences were often discussed.

CONCLUSIONS

People commonly wrote about contraceptive side effects and experiences using methods, highlighting the value of r/birthcontrol as a space to post about aspects of contraceptive use that are not well addressed by clinical contraceptive counseling. The value of real-time, open-access data on contraceptive users' interests is especially high given the shifting landscape of and increasing constraints on reproductive health care in the United States.

Equipping providers to offer novel MPTs: Developing counseling messages for the Dual Prevention Pill in clinical studies and beyond

Introduction

The pipeline for multi-purpose prevention technologies includes products that simultaneously prevent HIV, pregnancy and/or other sexually transmitted infections. Among these, the Dual Prevention Pill (DPP) is a daily pill co-formulating oral pre-exposure prophylaxis (PrEP), and combined oral contraception (COC). Clinical cross-over acceptability studies for the DPP require training providers to counsel on a combined product. From February 2021-April 2022, a working group of eight HIV and FP experts with clinical and implementation expertise developed counseling recommendations for the DPP based on existing PrEP/COC guidance.

Assessment of policy/guidelines options and implications

The working group conducted a mapping of counseling messages from COC and oral PrEP guidance and provider training materials. Six topics were prioritized: uptake, missed pills, side effects, discontinuation and switching, drug interactions and monitoring. Additional evidence and experts were consulted to answer outstanding questions and counseling recommendations for the DPP were developed. Missed pills was the topic with the most complexity, raising questions about whether women could "double up" on missed pills or skip the last week of the pack to recover protection faster. Uptake required aligning the time to reach protective levels for both DPP components and explaining the need to take DPP pills during week 4 of the pack. The potential intensity of DPP side effects, given the combination of oral PrEP with COC, was an important consideration. Discontinuation and switching looked at managing risk of HIV and unintended pregnancy when stopping or switching from the DPP. Guidance on drug interactions contended with differing contraindications for COC and PrEP. Monitoring required balancing clinical requirements with potential user burden.

Actionable recommendations

The working group developed counseling recommendations for the DPP to be tested in clinical acceptability studies. Uptake: Take one pill every day for the DPP until the pack is empty. Days 1-21 contain COC and oral PrEP. Days 22-28 do not contain COC to allow for monthly bleeding, but do contain oral PrEP and pills should be taken to maintain HIV protection. Take the DPP for 7 consecutive days to reach protective levels against pregnancy and HIV. Missed pills: If you miss 1 pill multiple times in a month or 2+ consecutive pills, take the DPP as soon as you remember. Do not take more than 2 pills in a day. If 2+ consecutive pills are missed, only take the last missed pill and discard the other missed pills. Side effects: You may experience side effects when you start using the DPP, including changes to monthly bleeding. Side effects are typically mild and go away without treatment. Discontinuation/switching: If you decide to discontinue use of the DPP, but want to be protected from HIV and/or unintended pregnancy, in most cases, you can begin using PrEP or another contraceptive method right away. Drug interactions: There are no drug-drug interactions from combining oral PrEP and COC in the DPP. Certain medications are not recommended due to their contraindication with oral PrEP or COC. Monitoring: You will need to get an HIV test prior to initiating or restarting the DPP, and every 3 months during DPP use. Your provider may recommend other screening or testing.

Discussion

Developing recommendations for the DPP as a novel MPT posed unique challenges, with implications for efficacy, cost, and user and provider comprehension and burden. Incorporating counseling recommendations into clinical cross-over acceptability studies allows for real-time feedback from providers and users. Supporting women with information to use the DPP correctly and confidently is critically important for eventual scale and commercialization.

Preconception, Interconception, and reproductive health screening tools: A systematic review

OBJECTIVE

To identify and describe the standardized interconception and preconception screening tools for reproductive health needs that are applicable in general outpatient clinical practice.

DATA SOURCES AND STUDY SETTING

This systematic review identifies research on pregnancy intention screening and counseling tools, and standardized approaches to preconception and interconception care. We focus on tools designed for clinical settings, but also include research tools with potential for clinical implementation. These tools may include a component of contraceptive counseling, but those focusing solely on contraceptive counseling were excluded. Data were collected from studies done in the United States between January 2000 and March 2022.

STUDY DESIGN

We performed a systematic literature search to generate a list of unique tools, assessed the quality of evidence supporting each tool, and described the peer-reviewed clinical applications of each. We used the Mixed Methods Appraisal Tool to appraise the quality of individual studies.

DATA COLLECTION/EXTRACTION METHODS

We searched PubMed, Web of Science, and CINAHL databases for standardized preconception and interconception health screening tools published in English from January 2000 through March 2022. We used keywords "preconception care," "interconception care," "family planning," "contraception," "reproductive health services," and "counseling." Utilizing the Preferred Reporting Items for Systematic Reviews guidelines, we screened titles and abstracts to identify studies for full text review.

PRINCIPAL FINDINGS

The search resulted in 15,399 studies. After removing 4172 duplicates, we screened 11,227 titles/abstracts and advanced 207 for full-text review. From these, we identified 53 eligible studies representing 22 tools/standardized approaches, of which 10 had evidence from randomized clinical trials. These ranged widely in design, setting, and population of study.

CONCLUSIONS

Clinicians have a choice of tools when implementing standard reproductive screening services. A growing body of research can inform the selection of an appropriate tool, and more study is needed to establish effects on long-term patient outcomes.

The Perfect Storm: Perceptions of Influencing Adults Regarding Latino Teen Pregnancy in Rural Communities

INTRODUCTION

Recognition of the importance of adolescents' environments in influencing their sexual and reproductive health (SRH) decision-making necessitates a deeper understanding of the role that community stakeholders play in shaping Adolescent and Young Adults (AYA) access to SRH education and care. We describe community stakeholders' knowledge, beliefs, and attitudes about AYA's SRH needs in three rural Latino communities in Kansas.

METHODS

Key stakeholders completed a written survey incorporating the theory of Planned Behavior to assess attitudes, norms, and intentions to support AYA's SRH education and access to care.

RESULTS

Across three rural immigrant community settings, respondents (N = 55) included 8 community health workers, 9 health care providers, 7 public health officials, 19 school health officials, and 12 community members. More than half self-identified as Latino (55%). Six (11%) participants, half of whom were in the health sector, thought SRH education would increase the likelihood that teens would engage in sexual activities. In contrast, other stakeholders thought that providing condoms (17, 30.9%), contraception other than condoms (14, 25.5%), and providing HPV immunization (5, 9.6%) would increase the likelihood of engaging in sexual activity. Ambivalence regarding support for SRH education and service provision prevailed across sectors, reflected even in the endorsement of the distribution of less effective contraceptive methods. Obstacles to care include immigration status, discrimination, lack of confidential services, and transportation.

CONCLUSION

Key stakeholders living in rural communities revealed misconceptions, negative attitudes, and ambivalent beliefs related to the delivery of SRH education and services, potentially creating barriers to AYA's successful access to care.

Reproductive health services: A missed opportunity in VA primary care?

OBJECTIVE

Integration of reproductive health services into comprehensive primary care is increasingly viewed as a strategy to address service gaps and improve patient-centered care. We assess receipt of contraceptive and prepregnancy health counseling among pregnancy-capable Veterans within Veterans Affairs (VA) primary care.

STUDY DESIGN

Data are from 1076 participants in a nationally representative, cross-sectional survey of women Veterans ages 18 to 45 with an overall survey response rate of 28%. Descriptive analyses and chi square tests of association were performed.

RESULTS

Only 44% of pregnancy-capable Veterans reported receiving any contraceptive and/or prepregnancy care from a VA primary care provider in the past year.

CONCLUSIONS

Although VA guidelines include reproductive services as a core component of primary care, additional efforts may be needed to promote routine provision of this care in practice.

Association of Primary Care Physicians' Individual- and Community-Level Characteristics With Contraceptive Service Provision to Medicaid Beneficiaries

Importance

Little is known about primary care physicians who provide contraceptive services to Medicaid beneficiaries. Evaluating this workforce may help explain barriers to accessing these services since contraceptive care access is critical for Medicaid beneficiaries' health.

Objective

To describe the primary care physician workforce that provides contraceptive services to Medicaid beneficiaries and explore the factors associated with their Medicaid contraceptive service provision.

Design, Setting, and Participants

This cross-sectional study, conducted from August 1 to October 10, 2022, used data from the Transformed Medicaid Statistical Information System from 2016 for primary care physicians from 4 specialties (family medicine, internal medicine, obstetrics and gynecology [OBGYN], and pediatrics).

Main Outcomes and Measures

The main outcomes were providing intrauterine devices (IUDs) or contraceptive implants to at least 1 Medicaid beneficiary, prescribing hormonal birth control methods (including a pill, patch, or ring) to at least 1 Medicaid beneficiary, the total number of Medicaid beneficiaries provided IUDs or implants, and the total number Medicaid beneficiaries prescribed hormonal birth control methods in 2016. Physician- and community-level factors associated with contraceptive care provision were assessed using multivariate regression methods.

Results

In the sample of 251 017 physicians (54% male; mean [SD] age, 49.17 [12.58] years), 28% were international medical graduates (IMGs) and 70% practiced in a state that had expanded Medicaid in 2016. Of the total physicians, 48% prescribed hormonal birth control methods while 10% provided IUDs or implants. For OBGYN physicians, compared with physicians younger than 35 years, being aged 35 to 44 years (odds ratio [OR], 3.51; 95% CI, 2.93-4.21), 45 to 54 years (OR, 3.01; 95% CI, 2.43-3.72), or 55 to 64 years (OR, 2.27; 95% CI, 1.82-2.83) was associated with higher odds of providing IUDs and implants. However, among family medicine physicians, age groups associated with lower odds of providing IUDs or implants were 45 to 54 years (OR, 0.66; 95% CI, 0.55-0.80), 55 to 64 years (OR, 0.51; 95% CI, 0.39-0.65), and 65 years or older (OR, 0.29; 95% CI, 0.19-0.44). Except for those specializing in OBGYN, being an IMG was associated with lower odds of providing hormonal contraceptive service (family medicine IMGs: OR, 0.80 [95% CI, 0.73-0.88]; internal medicine IMGs: OR, 0.85 [95% CI, 0.77-0.93]; and pediatric IMGs: OR, 0.85 [95% CI, 0.78-0.93]). Practicing in a state that expanded Medicaid by 2016 was associated with higher odds of prescribing hormonal contraception for family medicine (OR 1.50; 95% CI, 1.06-2.12) and internal medicine (OR, 1.71; 95% CI, 1.18-2.48) physicians but not for physicians from other specialties.

Conclusions and Relevance

In this cross-sectional study of primary care physicians, physician- and community-level factors, such as specialty, age, and the Medicaid expansion status of their state, were significantly associated with how they provided contraceptive services to Medicaid beneficiaries. However, the existence of associations varied across clinical specialties. Ensuring access to contraception among Medicaid beneficiaries may therefore require policy and program approaches tailored for different physician types.

Implementation of Title X Family Planning Services in Primary Care: A Qualitative Study of a Primary Care Network in Georgia

CONTEXT

There is increasing interest and value in integrating family planning services into primary care. Title X services provide an opportunity to expand low-cost access to these services. This study sought to identify and describe implementation factors that influenced the integration of a package of Title X services into a unique primary care setting within a Georgia primary care network whose community health center sites are primarily federally qualified health centers.

METHODS

We used an implementation science approach and were guided by the Consolidated Framework for Implementation Research. From December 2019 to September 2020, we conducted interviews with administrators and providers working at grantee and sub-grantee organizations about their experiences integrating Title X services into their existing practice.

RESULTS

Factors associated with the Inner Setting were especially important for integrating Title X in these settings. Participants identified specific needs related to resources such as electronic medical record (EMR) and reporting templates. Contextually specific clinical training for provision of long-acting reversible contraception and sexual health counseling, as well as administrative training for reporting and documentation efforts, was particularly needed. Grantee and sub-grantee organizations were able to leverage internal and external networks and adaptations to the intervention to successfully implement Title X services and to expand reach to new clients.

CONCLUSIONS

Integrating family planning into primary care may expand access to low-income and underserved populations. Approaches that incorporate flexibility and provide tailored resources for primary care settings such as EMR and reporting templates and trainings, and that leverage multiple forms of support and knowledge sharing, may be particularly important for helping to implement Title X services.

Pregnancy risks and contraceptive use among postpartum mothers in Cameroon: implications for improving the coverage of postpartum family planning services

BACKGROUND

The health hazards of short inter-birth intervals are severe in Cameroon. One-quarter of inter-birth intervals are less than 24 months and the probability of death before age 5 for children born after a short interval is double that associated with intervals of 36-47 months. We examine the risk of an unintended pregnancy in the 18 months following childbirth in Cameroon, taking into account the protective effects of lactational amenorrhea, delayed resumption of sex as well as contraceptive use.

METHODS

Data from 3007 postpartum women in the nationally representative 2018 Cameroon Demographic and Health Survey were used. Risk of an unintended pregnancy was defined from current status information on resumption of sex and menses, contraceptive use, desire for another child within 12 months, and, for the minority of pregnant women, whether the conception was intended. Predictors of risk, and of modern method use, were assessed by bivariate and multivariate analysis.

RESULTS

In the first 6 postpartum months, only 8% of women were fully at risk (i.e., sex and menses resumed but no contraceptive use), rising to 24% at 6-11 postpartum months, and further to 30% at months 12-17. Though 89% wanted to delay the next birth by at least 1 year, only 17% were currently using a modern method. Menstruating women were much more likely to be users than amenorrheic women: 27% versus 15% at months 12-17 postpartum. Urban and better educated women recorded higher contraceptive use but lower protection from other factors than rural, less educated women, with the net result that risk differed little across these population strata. Uptake of maternal and child health (MCH) services was high but only one-third of women had discussed family planning at a facility visit during the preceding 12 months.

CONCLUSIONS

These results underscore the need for improved postpartum family planning services by means of closer integration with mainstream health services. In view of evidence from other sources of heavy workload and weak motivation of health staff, this will require strong leadership. A related priority is to increase the number of staff trained in provision of long-acting methods, such as implants.

Comanagement with rheumatology and prescription biologics filled during pregnancy in women with rheumatic diseases: a retrospective analysis of US administrative claims data

OBJECTIVES

To evaluate comanagement with rheumatology and biological prescriptions filled during pregnancy among women with axial spondyloarthritis (axSpA), rheumatoid arthritis (RA) or psoriatic arthritis (PsA) and to examine factors associated with receiving comanagement with rheumatology during pregnancy.

DESIGN

A retrospective analysis of US claims data.

SETTING

Commercially insured enrollees using data from the 2013-2018 IBM MarketScan Commercial Claims and Encounters Database.

PARTICIPANTS

We identified 4131 pregnant women aged ≤55 years from the 2013-2018 IBM MarketScan Commercial Claims and Encounters Database with an International Classification of Disease, 9th Revision/10th Revision codes for RA, axSpA or PsA, with continuous enrolment at ≥3 months before the date of the last menstrual period (LMP) (index date) and throughout pregnancy.

PRIMARY OUTCOMES

Filled biologics (prescriptions and infusions) claims were categorised by 90 days before the LMP and trimester, as were primary care, obstetrician and rheumatological claims.

RESULTS

The prevalence of axSpA, RA and PsA was 0.7%, 0.2% and 0.04% among reproductive age women. The average maternal age was 32.7 years (SD 5.7). During pregnancy, 9.1% of those with axSpA (n=2,410) and 56.4% of those with RA/PsA (n=1,721) had a rheumatological claim. Biologics claims were less common among those with axSpA (90 days before LMP: 1.6%, during pregnancy: 1.1%) than those with RA/PsA (90 days before LMP: 11.9%, during pregnancy: 6.9%). Medications during pregnancy included corticosteroids (axSpA: 0.3%, RA/PsA: 2.2%), non-biological disease-modifying antirheumatic drugs (axSpA: 0.2%, RA/PsA: 1.7%), non-steroidal anti-inflammatory drugs (axSpA: 0.2%, RA/PsA: 1.3%) and opioids (axSpA: 0.2%, RA/PsA: 0.6%). Established rheumatological care and biologics claims during the 90 days before LMP showed good prediction accuracy for receiving comanagement with rheumatology during pregnancy (axSpA: area under the receiver operator curve (AUC) 0.73, RA/PsA: AUC 0.70).

CONCLUSION

Comanagement with rheumatology during pregnancy occurs infrequently, especially for women with axSpA. Biologics claims during pregnancy may not align with published guidelines. Future research is warranted to improve comanagement with rheumatology during pregnancy.

Women's Perspectives on a Reproductive Health Services Screening Question: An Alternative to Pregnancy Intention Screening

Background

Current efforts to integrate reproductive health care into primary care in the United States involve assessing pregnancy intentions and reproductive goals, which are often not meaningful or attainable for some. Alternatively, we designed a reproductive health services-based screening question: "Can I help you with any reproductive health services today, such as preventing pregnancy or planning a healthy pregnancy?" In this study, we describe women's interpretations of this question as part of a larger study, exploring perspectives on reproductive health care quality in primary care.

Materials and Methods

We utilized a third-party research firm to recruit New York women of reproductive age (18-45), who visited a primary care provider in the past year. We conducted five focus groups and eight interviews (N = 30). Semistructured guides queried participants on interpretations of the screening question and preferences for raising reproductive health concerns during a primary care visit. We employed inductive thematic analysis.

Results

Participants interpreted the question as offering contraception or pregnancy counseling and care, although younger participants also understood it as offering sexual and reproductive health services broadly. Participants also connected the question with discussions about their ability to conceive. Some participants described experiences with provider assumptions and implicit bias. Tensions emerged around accepting primary care as a setting for reproductive health due to a perceived lack of specialized training.

Conclusions

Participants interpreted the screening question as intended, indicating face validity. Primary care settings should increase patients' awareness of reproductive health service availability, such as by routinely introducing a services-based screening question.

Improvement of pregnancy counselling and contraception counselling and documentation in a single rheumatology academic practice: a quality improvement project

The purpose of this quality improvement project was to improve the rate of pregnancy counselling and documentation regarding the risk of being on teratogenic medications, including leflunomide, mycophenolate, methotrexate or cyclophosphamide in women of childbearing age (17–50 years). Our goal was to increase documentation rates by 25% in 6 months. We first performed an EMR chart review of 103 women who were seen in the 6 months prior to intervention by faculty at a single rheumatology academic centre. We then determined how many of those women had documented contraception or pregnancy counselling, which included written documentation anywhere in the note or ICD codes which were specific to pregnancy counselling or contraception counselling. Interventions were then implemented. The percentage of women who had documented pregnancy counselling did not change preintervention and postintervention; preintervention 37% of women received documented pregnancy counselling and postintervention 35% of women received documented pregnancy counselling. The percentage of women who had documented contraception counselling did however change preintervention and postintervention; preintervention 37% of women received documented contraception counselling and postintervention 51% of women received documented contraception counselling, which is a 14% improvement.

Providers' approaches to contraceptive provision in Cape Town

Background

Health care providers can play a significant role in empowering women to make informed decisions when selecting suitable contraceptive methods during contraceptive counseling. This study explores primary care providers' perspectives and approaches to contraceptive service provision for women attending public sector clinics in South Africa, with the intention of ascertaining established practices and training needs.

Methods

Ten in-depth interviews were conducted at five primary health care facilities in urban areas in Cape Town, South Africa. Eligible participants included nurses providing contraceptive services and willing to participate in the study. The qualitative software package NVivo was used to sort and manage data. Data was analyzed using a thematic analysis approach.

Results

Overall, providers emphasized supporting women in contraceptive decision-making. Sexual and reproductive health training increased providers confidence to deliver appropriate contraceptive services. Contraceptive prescribing practices were influenced by women's medical history and preferred bleeding patterns. Providers' concerns about adherence to methods for younger women and suspected adverse events for older women impacted on prescribing. Challenges experienced when providing contraceptive services included: contraceptive stockouts; time constraints of employed women accessing the service; and their work pressure due to providing other health services.

Discussion

Health care providers play a critical role in facilitating women's right to access high quality contraceptive services. Providers saw themselves as negotiators during contraceptive counseling. They considered both women's preferences and their own recommendations for contraception, to provide information that would enable women to make informed contraceptive decisions. By reinforcing this approach to contraceptive counseling and focusing on shared decision-making, should encourage autonomy in method selection and limit the influence of provider's contraceptive method selection.

Health workers' values and preferences regarding contraceptive methods globally: A systematic review

OBJECTIVE

We sought to systematically review the literature on health workers' values and preferences related to contraceptive methods.

STUDY DESIGN

As part of a larger review, we searched ten electronic databases for published articles from January 1, 2005 through July 27, 2020. We included studies that reported qualitative or quantitative data from the perspective of health workers providing family planning services globally.

RESULTS

Forty-one studies met our inclusion criteria. These studies included 12,643 health workers and were conducted in 27 countries. Health worker values and preferences for contraceptive methods were affected by factors related to contraceptive method characteristics (e.g., bleeding pattern and convenience), the contraceptive user (e.g., medical history, parity), and the health worker themselves (e.g., training, environment). Differences were also noted between various professions/specialties (e.g., comfort level with contraceptive methods, depth of experience). While contraceptive counseling and provision were influenced by health worker values and preferences, they were also affected by health worker misconceptions and biases.

CONCLUSION

Health worker values and preferences for contraception are affected by the client's history, medical eligibility, and the health worker context. Provision of contraception that is affected by harmful bias towards certain populations or about certain methods can negatively affect patient-centered care. Future work should address knowledge gaps and health worker biases by improving and standardizing education and training globally, to ensure high-quality, rights-based, and patient-centered contraceptive services.

Multilevel Influences on Providers' Delivery of Contraceptive Services: A Qualitative Thematic Analysis

Introduction:

Access to a full range of contraceptive services is essential for quality health care. Contraceptive provision practices of primary care providers play an important role in patients' decision-making about their reproductive health care. Understanding the multilevel factors influencing contraceptive care delivery in primary care settings is critical for advancing quality care. This study offers an in-depth examination of influences on providers' delivery of contraceptive services across multiple primary care specialties and practice settings to identify issues and strategies to improve care.

Materials and Methods:

Twenty-four in-depth face-to-face interviews were conducted in 2017 with primary care providers, including family physicians, gynecologists, pediatricians, and nurse practitioners from academic settings, private practices, and health centers. Interviews were transcribed and analyzed thematically.

Results:

Providers described a complex set of influences on their provision of contraception across multiple ecological contexts. Seven major themes emerged from the qualitative analysis, including six types of influence on provision of contraception: organizational, individual provider-related, structural and policy, individual patient-related, community, and the lack of influences or barriers. Providers also discussed the sources they access for information about evidence-based contraception counseling.

Conclusions:

A diverse set of providers described a complex system in which multiple concentric ecological contexts both positively and negatively influence the ways in which they provide contraceptive services to their patients. To close the gaps in contraceptive service delivery, it is important to recognize that both barriers and facilitators to patient-centered contraceptive counseling exist simultaneously across multiple ecological contexts.

Quantitative and qualitative impact of One Key Question on primary care providers' contraceptive counseling at routine preventive health visits

OBJECTIVES

One Key Question (OKQ) is a clinical screening tool to assess pregnancy desire in the next year. We aimed to 1) describe the effect of OKQ implementation on contraceptive counseling rates at preventive health visits and 2) evaluate primary care providers' perception of OKQ implementation on their contraceptive counseling practices.

STUDY DESIGN

We performed a quantitative retrospective chart review of preventive health visits at eight federally qualified health centers in Utah between 2014 and 2017. Implementation of OKQ included a brief training and inclusion of OKQ in the electronic medical record. Providers received OKQ training in August 2015 and re-training in March 2017. We assessed OKQ and contraceptive counseling documentation rates using interrupted-time-series analysis. We then conducted semi-structured interviews with providers and queried them about the impact of OKQ. We identified dominant themes using modified grounded theory to create an explanatory framework.

RESULTS

Abstracting 6634 charts yielded 9840 visits with 56 unique providers (51% physician assistant, 34% physician, 14% nurse practitioner). Interrupted-time-series analysis showed a documentation increase of OKQ in late 2015 (2.6%) and again in spring 2017 (9%), however rates remained low. Contraceptive counseling rates (39.7%) did not change after OKQ implementation. Charts with evidence of a current contraceptive method were less likely to have a OKQ response documented. Interviewees reported OKQ's algorithm did not alter their contraceptive counseling.

CONCLUSIONS

OKQ did not change documented rates of contraceptive counseling and uptake was low in quantitative and qualitative analyses. Our study suggests limited usefulness of OKQ in the primary care setting.

IMPLICATIONS

Implementation of the One Key Question tool through training and optional EHR field did not increase documented rates of contraceptive counseling in a large federally qualified health center or affect provider contraceptive counseling. Our study suggests limited usefulness of OKQ as a robust screening tool in this primary care setting.

Facilitators of and Barriers to Successful Implementation of the One Key Question® Pregnancy Intention Screening Tool

Background:

One Key Question^® (OKQ) is a tool that embeds a patient-centered screening into routine visits with the goal of making pregnancy intention screening universal, but widespread implementation has not yet been adopted. We aimed to explore the barriers and facilitators of OKQ implementation to better understand how to best implement the tool across different settings.

Methods:

We invited staff and clinicians from one obstetrics and gynecology clinic and one family medicine clinic, which previously implemented OKQ, to complete surveys and qualitative interviews about their experiences with the tool. The interview guide and thematic analysis of the interview transcripts were informed by the Consolidated Framework for Implementation Research (CFIR).

Main Findings:

Major facilitators of OKQ implementation are the simplicity of the tool, engagement of clinic leadership, and compatibility between the perceived goals of the tool and those of practice staff and clinicians. Although participants indicated that OKQ had a minimal impact on clinic workflow during its implementation, preimplementation time concerns were a major barrier to implementation in both clinics. Barriers seen in the family medicine practice included OKQ distracting from the visit agenda, and concerns about the OKQ gold standard protocol of screening each patient at every visit. Participants even suggested asking OKQ only during annual check-up appointments.

Conclusions:

The perceived alignment between the tool's goals and those of clinic stakeholders was an important facilitator of OKQ implementation success. However, characteristics of the clinic setting, such as competing medical priorities and time constraints, influenced initial attitudes toward the feasibility of the intervention. Clinical Trial Registration Number: NCT03947788

Curricular Considerations for Preparing Student Pharmacists to Prescribe Hormonal Contraception

In 2014, the pharmacist's role in the United States expanded to include prescribing hormonal contraception, and this practice is currently addressed by policy in 14 states and the District of Columbia. Training and education requirements for this expanded scope of practice vary between states and are changing rapidly. The objective of this review is to examine how student pharmacists are taught to provide contraceptive care, specifically for prescribing ongoing hormonal contraception and emergency contraception, and to identify potential gaps in the United States pharmacy curricula related to contraception. Despite steady adoption into community pharmacy practice, there is sparse literature assessing educational methods used to teach contraceptive care. This review offers recommendations to promote consistent and comprehensive student pharmacist education in providing contraceptive care across institutions, regardless of state policy status.

Engaging Stakeholders in the Development of a Reproductive Goals Decision AID for Women with Cystic Fibrosis

Objective: More people with cystic fibrosis (pwCF) are reaching adulthood and considering their reproductive futures. Unfortunately, many pwCF report gaps in their reproductive healthcare. We describe measures of stakeholder engagement in developing a reproductive goals decision aid for women with CF called MyVoice:CF. Methods: Stakeholders reviewed the content, design, and usability of the tool, which was informed by prior research related to CF family planning experiences and preferences as well as a conceptual understanding of reproductive decision making. We evaluated stakeholder engagement via process measures and outcomes of stakeholder involvement. We collected data via recorded stakeholder recommendations and surveys. Results: Fourteen stakeholders participated and the majority described their role on the project as "collaborator", "advisor", or "expert." Most felt their expectations for the project were met or exceeded, that they had contributed significantly, and that they received sufficient and frequent information about the process. All stakeholders provided recommen-dations and clarified aims for a CF-specific family planning tool, including its content and focus on facilitating shared decision making. Discussion: Utilizing meaningful stakeholder contributions, we developed MyVoice:CF, a novel web-based decision aid to help women with CF engage in shared decision-making regarding their reproductive goals. Practical Value: Our findings from working with stakeholders for MyVoice:CF indicate that disease-specific reproductive health resources can and should be designed with input from individuals in the relevant communities.

Effectiveness of Contraceptive Decision Aids in Adolescents and Young Adults: A Systematic Review

BACKGROUND

Contraceptive decision aids may support adolescents and young adults (AYA) in choosing contraceptive methods that fit their unique reproductive health needs.

OBJECTIVE

To provide a systematic review of studies examining the effectiveness of contraceptive decision aids in AYA.

MATERIALS AND METHODS

A systematic search was conducted of studies published between January 1, 2011, and March 31, 2021 using PubMed, Cochrane, and ClinicalTrials.gov. Studies were included if a contraceptive decision aid (ie, paper handout, mobile application, website, or video) was evaluated in AYA populations (age ≤30 years) in the United States. The primary outcome was decision aid effectiveness (ie, change in contraceptive knowledge, interest in contraception, contraceptive use, unintended pregnancies, and satisfaction with the decision aid).

RESULTS

Seven randomized controlled trials and 3 pre-post studies, reporting on 3725 AYA (range, 11-30 years), met inclusion criteria. No studies were excluded due to risk of bias. The methodologies and results were heterogeneous, but most consistently demonstrated increased contraceptive knowledge.

CONCLUSION

Ten studies evaluated a range of contraceptive decision aid formats for AYA. Decision aids appear to be effective at increasing contraceptive knowledge temporarily, but their effect on other contraceptive outcomes is unclear. Future research should evaluate decision aids specifically in adolescents.

"Did I Choose a Birth Control Method Yet?": Health Care and Women's Contraceptive Decision-Making

In the United States, unintended pregnancy is medicalized, having been labeled a health problem and "treated" with contraception. Scholars find women's access to contraception is simultaneously facilitated and constrained by health care system actors and its structure. Yet, beyond naming these barriers, less research centers women's experiences making contraceptive decisions as they encounter such barriers. Through in-depth, semi-structured interviews with 86 diverse, self-identified women, this study explores how the medicalization of unintended pregnancy has influenced women's contraceptive access and decision-making. We highlight the breadth of such influence across multiple contraceptive types and health care contexts; namely, we find the two most salient forces shaping women's contraceptive decisions to be their insurance coverage and providers' contraceptive counseling. Within these two categories, we offer crucial nuance to demonstrate how these oft-cited barriers implicitly and explicitly influence women's decisions. Paradoxically, it is the health care system, itself, that both offers yet constrains women's contraceptive decisions.

Use of open-text responses to recode categorical survey data on postpartum contraception use among women in the United States: A mixed-methods inquiry of Pregnancy Risk Assessment Monitoring System data

BACKGROUND

Postpartum contraception prevents unintended pregnancies and short interpregnancy intervals. The Pregnancy Risk Assessment Monitoring System (PRAMS) collects population-based data on postpartum contraception nonuse and reasons for not using postpartum contraception. In addition to quantitative questions, PRAMS collects open-text responses that are typically left unused by secondary quantitative analyses. However, abundant preexisting open-text data can serve as a resource for improving quantitative measurement accuracy and qualitatively uncovering unexpected responses. We used PRAMS survey questions to explore unprompted reasons for not using postpartum contraception and offer insight into the validity of categorical responses.

METHODS AND FINDINGS

We used 31,208 categorical 2012 PRAMS survey responses from postpartum women in the US to calculate original prevalences of postpartum contraception use and nonuse and reasons for contraception nonuse. A content analysis of open-text responses systematically recoded data to mitigate survey bias and ensure consistency, resulting in adjusted prevalence calculations and identification of other nonuse themes. Recoded contraception nonuse slightly differed from original reports (21.5% versus 19.4%). Both calculations showed that many respondents reporting nonuse may be at a low risk for pregnancy due to factors like tubal ligation or abstinence. Most frequent nonuse reasons were not wanting to use birth control (27.1%) and side effect concerns (25.0%). Other open-text responses showed common themes of infertility, and breastfeeding as contraception. Comparing quantitative and qualitative responses revealed contradicting information, suggesting respondent misinterpretation and confusion surrounding the term "pregnancy prevention." Though this analysis may be limited by manual coding error and researcher biases, we avoided coding exhaustion via 1-hour coding periods and validated reliability through intercoder kappa scores.

CONCLUSIONS

In this study, we observed that respondents reporting contraception nonuse often described other methods of pregnancy prevention and contraception barriers that were not included in categorical response options. Open-text responses shed light on a more comprehensive list of pregnancy prevention methods and nonuse options. Our findings contribute to survey questions that can lead to more accurate depiction of postpartum contraceptive behavior. Additionally, future use of these qualitative methods may be used to improve other health behavior survey development and resulting data.

Using the Social-Ecological Model to Understand the Current Perspective of Contraceptive Use in the United States: A Narrative Literature Review

Contraceptive use is deemed one of the 10 greatest public health achievements of the 20th century because its benefits are universally acknowledged as a cornerstone for reducing global maternal morbidity and mortality. However, although the adoption of the Affordable Care Act in the United States (US) enhanced access to preventive health services, as well as increased contraceptive use, a considerable proportion of reproductive-aged women still have unmet reproductive health needs. Current data indicates gaps in contraceptive use patterns in the US, particularly among low-income women and those from racial/ethnic and gender minority subgroups, necessitating further investigation using an ecological approach. This narrative literature review aims to investigate the current perspective of contraceptive use in the US using the social-ecological model (SEM). Based on SEM levels, barriers to contraceptive use entail the following levels: individual (e.g., misbelief about the side effects of contraceptives), interpersonal (e.g., influence of family and friends), institutional (e.g., lack of training on how to use different types of contraceptives), community (e.g., societal stigma and shame), and policy (e.g., restrictive federal and states policies). Access to contraceptives for women is a system-level issue that necessitates consideration for multilevel strategies by key stakeholders to improve contraceptive uptake among vulnerable populations.

Are healthcare providers and young people talking about sexuality? A scoping review to characterize conversations and identify barriers

BACKGROUND

Conversations about sexuality with healthcare providers (HCPs) are critical to youth's positive development, including youth with disabilities or chronic conditions. Yet, little is known about the characteristics of sexuality conversations with youth in healthcare settings. This scoping review examined the nature and extent of sexuality conversations between HCPs and youth (with and without a disability or chronic condition) and aimed to identify barriers to these conversations.

METHODS

Scoping review methodology using rapid review principles was employed.

INCLUSION CRITERIA

studies published between 2009 and 2019; examined conversations between HCPs and youth aged 21 and below; addressed sexuality; and took place in a healthcare setting. Study characteristics were described and clustered into thematic groups.

RESULTS

Of the 5543 identified, 32 articles were included. Articles addressed (i) the content of sexuality conversations, (ii) prevalence of sexuality conversations and (iii) barriers to discussing sexuality. The content of sexuality discussions was largely biologically focused. The prevalence of sexuality discussions varied, with some discrepancy between youth-reported and HCP-reported rates. Seven barriers (three personal and four systemic) were identified. Youth with disabilities or chronic conditions were vastly under-represented in the published literature.

CONCLUSIONS

This study highlighted that sexuality is an underexplored topic between HCPs and young people, especially young people with disabilities and/or chronic conditions. Given the importance of sexuality to young people's mental and physical health, research addressing barriers to these discussions and development of evidence-informed resources to support HCPs and youth to engage in conversations about sexuality should be a priority.

Development and Pilot Testing of a Patient-Centered Web-Based Reproductive Decision Support Tool for Primary Care

BACKGROUND

Patient-centered counseling to help women achieve their reproductive goals is an essential yet often absent component of primary care.

OBJECTIVE

We developed and piloted MyPath, a novel web-based decision support tool integrating reproductive goals assessment, information about optimizing health before pregnancy, and contraceptive decision support, for use prior to primary care visits in the Veterans Administration (VA).

DESIGN

We created MyPath using best practices for decision tool development, including a conceptual framework informed by theory and user-centered design with input from patients, providers, and scientific experts. We conducted a non-randomized pilot in two VA Women's Health primary care clinics. A control group (n = 28) was recruited prior to and intervention group (n = 30) recruited after introduction of MyPath into clinics.

PARTICIPANTS

Women Veterans ages 18-44 with an upcoming visit scheduled with one of eight providers.

INTERVENTIONS

After recruitment of controls, providers and staff received a brief introduction to MyPath. Patients scheduled to see providers in the intervention phase used MyPath on an iPad in the waiting room prior to their visit.

MAIN MEASURES

Acceptability, feasibility, discussions about pregnancy and/or contraceptive needs, and contraceptive decision quality by a survey of participants and providers.

KEY RESULTS

Nearly all participants who used MyPath reported they learned new information (97%) and would recommend it to other Veterans (93%). No providers reported that MyPath significantly increased workload. A greater proportion of intervention participants reported having discussions about reproductive needs in their visit compared to controls (93% vs 68%; p = 0.02). Intervention participants also experienced greater increases in pre-/post-visit knowledge and communication self-efficacy and a trend towards greater reduction in contraceptive decision conflict compared to controls.

CONCLUSIONS

MyPath was highly acceptable to women, increased the proportion of primary care visits addressing reproductive needs, and improved decision quality without increasing providers' perceived workload. A larger randomized evaluation of effectiveness is warranted.

Contraceptive counseling experiences among women attending HIV care and treatment centers: A national survey in Kenya

OBJECTIVES

To characterize contraceptive counseling experiences among women living with HIV (WLWH) receiving HIV care in Kenya.

STUDY DESIGN

Sexually active, WLWH aged 15 to 49 years were purposively sampled from 109 high-volume HIV Care and Treatment Centers in Kenya between June and September 2016. Cross-sectional surveys were administered to enroll women on a tablet using Open Data Kit. Poisson generalized linear regression models adjusted for facility-level clustering were used to examine cofactors for receiving family planning (FP) counseling with a provider.

RESULTS

Overall, 4805 WLWH were enrolled, 60% reported they received FP counseling during the last year, 72% of whom reported they were counseled about benefits of birth spacing and limiting. Most women who received FP counseling were married (64%) and discussed FP with their partner (78%). Use of FP in the last month (adjusted Prevalence Ratio [aPR] = 1.74, 95% confidence interval [CI]: 1.41-2.15, p < 0.001), desire for children in >2 years (aPR = 1.18, 95% CI: 1.09-1.28, p < 0.001), and concern about contraceptive side-effects (aPR = 1.13, 95% CI 1.02-1.25, p < 0.05) were significantly higher among WLWH who received FP counseling compared to those that did not.

CONCLUSIONS

Over one-third of WLWH did not receiving FP counseling with an HIV care provider during the last year, and counseling was more commonly reported among women who were using FP or desired children in >2 years.

IMPLICATIONS

There are missed opportunities for FP counseling in HIV care. FP integration in HIV care could improve FP access and birth spacing or limiting among WLWH.

Multimorbidity and use of reversible contraception: Results from a Canadian cross-sectional survey

OBJECTIVE

Despite the importance of contraception for pregnancy planning in females with chronic conditions, little is known about contraception use in those with two or more chronic conditions-i.e., multimorbidity. We examined contraception use among females with multimorbidity, one chronic condition, and no identified chronic conditions.

STUDY DESIGN

We used data from the 2015 to 2016 Canadian Community Health Survey on 15 to 49-year-old females at risk of unintended pregnancy (n = 12,741), comparing females with ≥2 chronic conditions (21.3%) and one chronic condition (27.7%) to those with no identified chronic conditions (51.0%). We used modified Poisson regression to derive adjusted prevalence ratios (aPR) for any contraception vs no contraception, and multinomial logistic regression to derive adjusted odds ratios (aOR) for highly effective, moderately effective, and no contraception vs less effective contraception.

RESULTS

Compared to females with no identified chronic conditions, those with multimorbidity were less likely to use any contraception (aPR 0.93, 95% CI 0.89 - 0.98). Females with multimorbidity were more likely than those with no identified chronic conditions to use no contraception (aOR 1.29, 95% CI 1.13 - 1.46), with little to no difference in the use of highly (aOR 1.08, 95% CI 0.91 - 1.29) or moderately effective contraception (aOR 0.98, 95% CI 0.86 - 1.13), vs less effective contraception. There were no differences between females with one chronic condition and no identified chronic conditions.

CONCLUSION

The lower overall rate of contraception use in females with multimorbidity reflects a need for more attention to family planning in this population, with prompt and convenient access to highly effective options.

Over-the-counter oral contraceptive use among women in Mexico: results from a national survey

AIM

In Mexico, many pharmacies sell oral contraceptives (OCs) over the counter (OTC); however, little is known about the background characteristics of OTC pill users. The primary objective of this study was to understand the characteristics of OTC OC users in Mexico, including whether there were differences by age, urbanicity, and insurance status. This information is instructive as other countries explore allowing OTC access to OCs.

METHODS

We analysed the nationally representative 2014 Mexican National Survey of Demographic Dynamics (ENADID) among a sample of OC users aged 15-54 years (n=1970). We performed multivariable logistic models to understand the characteristics associated with OTC access, with age, urbanicity, and insurance status as our primary predictors of interest. Additionally, we descriptively explored knowledge of how frequently to take OCs by pill source and age.

RESULTS

Some 54% of pill users, including 66% of those aged 15-17 years, obtained their OCs OTC. In multivariable regression we found no differences in OTC access by age. However, being uninsured (adjusted odds ratio (AOR) 1.86, 95% CI 1.23 to 2.82) (compared with employer-based public insurance) and living in an urban area (AOR 4.73, 95% CI 3.37 to 6.66) (compared with rural area) were associated with a higher odds of OTC access among pill users. Women's knowledge of how frequently to take OCs was similar between OTC and prescription users within age groups.

CONCLUSIONS

These findings point to the importance of OTC availability of OCs for pill users of all ages and uninsured and urban women in Mexico in particular.

From training to implementation: Improving contraceptive practices in South Carolina

OBJECTIVE

Capacity building and training to improve contraceptive care is essential for patient-centered care and reproductive autonomy. This study assessed the feasibility of translating the knowledge and skills gained from contraception trainings into improvements in practice.

STUDY DESIGN

Participants completed surveys following contraceptive care trainings provided to family planning clinic and hospital obstetric providers and staff as a part of the Choose Well contraceptive access initiative in South Carolina. Surveys assessed participants' intent to change their practice post-training and anticipated barriers to implementing change. A mixed-methods approach was utilized including descriptive analysis of Likert scale responses and thematic content analysis to synthesize open-ended, qualitative responses.

RESULTS

Data were collected from 160 contraceptive training sessions provided to 4814 clinical and administrative staff between 2017 and 2019. Post-training surveys were completed by 3464 participants (72%), and of these, 2978 answered questions related to the study outcomes. Most respondents (n = 2390; 80.7%) indicated intent to change their practice and 35.5% (n = 1044) anticipated barriers to implementing intended changes. Across all training categories, organizational factors (time constraints, policies and practices, infrastructure/resources) were the most frequently perceived barrier to improving contraceptive services. Structural factors related to cost for patients were also identified as barriers to IUD and implant provision.

CONCLUSION

The trainings were successful in influencing family planning staff and providers' intent to improve their contraceptive practices, yet some anticipated barriers in translating training into practice. Improvements in organizational and structural policies are critical to realizing the benefits of trainings in advancing quality contraceptive care.

IMPLICATIONS

In addition to training, coordinated efforts to address organizational practices and resources, coupled with system-level policy changes are essential to facilitate the delivery and sustainability of patient-centered contraceptive care.

Pregnancy Risk Screening and Counseling for Women Veterans: Piloting the One Key Question in the Veterans Healthcare Administration

OBJECTIVES

Women veterans have a high prevalence of comorbidities that increase the risk of adverse pregnancy outcomes. Screening for pregnancy desires in primary care provider (PCP) visits offers an opportunity to optimize preconception health. This pilot quality improvement initiative sought to assess Veterans Healthcare Administration provider preferences on One Key Question (OKQ) implementation, identification of veterans' reproductive needs, and the effect of training on documentation in a women's primary care clinic in Salt Lake City, Utah.

METHODS

We hosted OKQ training sessions for providers and staff, audio recorded group discussions on implementation barriers, and explored themes. Women veterans presenting for a PCP visit in July 2018 self-completed a paper OKQ screening tool. We calculated summary statistics on responses. We conducted a pre-post analysis, with respect to training sessions, to measure for changes in family planning documentation during PCP visits.

RESULTS

Nineteen providers and staff completed the training. They acknowledged the importance, but believed that the screening tool should be completed by veterans and not be provider prompted. Forty-two women veterans completed the screening tool: 21% desired pregnancy in the next year and 26% desired contraceptive information. Chart reviews found a nonsignificant increase in current contraceptive method documentation between periods (20% vs 37%; P = 0.08), a decline in documentation of reproductive goals (22% vs 3%; P = 0.02), and no significant change in counseling.

CONCLUSIONS

Veterans identify reproductive needs via the OKQ screening tool, but provider documentation did not reflect changes in care following training. Further study is necessary to develop an optimal, patient-centered tool and implementation plan to support women veterans in their reproductive goals.

Physician awareness regarding contraceptive counselling in women with chronic disease

INTRODUCTION

Contraceptive counselling is essential in women with chronic disease, though it is frequently overlooked. We aimed to assess practices and awareness in contraceptive counselling in hospital physicians caring for reproductive age women with chronic disease.

METHODS

A questionnaire was distributed in April 2017 to physicians from 16 medical specialties in a tertiary care hospital in Portugal. Statistical analysis performed using Microsoft Office Excel^® and IBM SPSS-Statistics^®.

RESULTS

Two-hundred physicians participated in the survey: 59.5% were female, 55% under 35 years-old and 48.5% were residents. Only 26.5% practiced in surgical specialties. Two-thirds consistently inquired about the use of contraception. Most referred patients to Family Planning services or performed contraceptive counselling when pregnancy posed significant health risks (89.0%), when prescribing teratogenic medication (79.5%) or drugs with potential interaction with contraceptives (75.0%). Lack of training in contraception was the main reason for not referring patients to Family Planning services. While 83% considered counselling very important, only 5% had recently undergone training and 12.5% felt knowledgeable enough to perform it. Only 12.5% were aware of the institution's Family Planning resources. Female gender, non-surgical specialty, age over 35 years-old and over 10 years since specialisation were positively associated with awareness.

CONCLUSION

Most physicians addressed contraceptive management in women with comorbidities, but adequate training is lacking. Our results highlight the importance of communication between health care providers to achieve an adequate and multidisciplinary approach to reproductive and general health goals.

What do service providers in Southern Ethiopia say about barriers to using youth-friendly sexual and reproductive health services for adolescents?: Qualitative study

Background

In Ethiopia, the utilization coverage of adolescent-friendly health services (AFSRHs) ranged only from 9 to 55% and it was the lowest of all Sub-Saharan African countries in 2016. Little is known why adolescents were not accessing the existing services to the side of healthcare providers.

Objective

The aim of this study is to explore contextual perceived and actual barriers to accessing AFSRHs by adolescents in Southern Ethiopia.

Methods

Phenomenological study design supplemented with observation was used to explore perceived and actual barriers to accessing AFSRHs in 2020. Criterion sampling was used to select study participants. In-depth interviews with healthcare providers and non-specialist sexual and reproductive healthcare providers were conducted. Transcribed interviews and observations were imported to Open Code 4.02 for coding, categorizing, and creating themes. Finally, barriers to accessing existing services were explained using thematic analysis.

Results

The study explores contextual barriers to accessing sexual and reproductive health services in five emergent themes. According to providers’ points of view, the barriers include ranging from providers (e.g. poor providers’ competency), health facilities (e.g. supply constraints and unsupportive environment), adolescents (e.g. perceived lack of information and attitude towards SRHs), community (e.g. lack of parental and social support), and broader health system (e.g. poor implementation and multi-sectorial engagement).

Conclusion

As to providers, adolescents face multiple barriers to accessing youth friendly sexual and reproductive health services. Healthcare facilities and all levels of the healthcare system should implement varieties of approaches to increase access to the services for adolescents. Given the lack of progress in utilization of adolescents- youth friendly sexual and reproductive services, the existing strategy should be re-evaluated and new interventions at all levels of the healthcare system are needed. Moreover, implementation research is required at system level factors.

A Novel Contraception Counseling and Shared Decision-Making Curriculum for Internal Medicine Residents

INTRODUCTION

Many women of reproductive age with complex medical conditions receive primary care through an internal medicine (IM) physician rather than an obstetrician/gynecologist. Long-acting reversible contraception methods are the most effective form of contraception; however, IM residents are not routinely trained in them. Infrequent training in, inadequate knowledge of, and discomfort with contraception counseling limit the counseling performed by IM residents. Shared decision-making (SDM) is a method of patient-centered communication that can improve communication about patient preferences and increase patient satisfaction with and adherence to contraception. We developed a curriculum to teach contraception counseling under the framework of SDM for IM residents.

METHODS

The curriculum focused on contraception counseling through the lens of SDM designed for IM and medicine/pediatrics residents (PGY 2-PGY 4). We adapted an existing seven-step model of SDM to fit elements of contraception counseling. The curriculum consisted of a didactic teaching session with integration of an instructional video and structured interactive discussion. The session lasted 60 minutes.

RESULTS

Fifty-eight residents participated in the curriculum. On pre- and postcurriculum surveys, residents reported improvement in contraception knowledge (overall mean precurriculum = 57%, postcurriculum = 70%, p < .001) and comfort with contraception counseling (overall mean precurriculum = 3.2, postcurriculum = 3.6, p < .01). Residents expressed strong support for SDM before and after the curriculum.

DISCUSSION

Based on the survey results, the curriculum successfully addressed gaps in residents' comfort with contraception counseling and knowledge of contraception side effects and efficacy.

Missed Opportunities for Discussing Contraception in Adolescent Primary Care

BACKGROUND

Over half of adolescents are sexually active by age 18 years and represent half of sexually transmitted infections (STI). These individuals often do not obtain routine medical care, so discussing contraception at each visit becomes imperative. Our study objectives were to determine the frequency of visits before contraception was discussed/initiated, and to assess factors affecting primary care contraception provision.

METHODS

A retrospective chart review (January 2009-June 2019) was conducted for preventive, follow-up, and sick visits; Title X confidential visits were excluded. Questions were asked about method at start and end of the visit. Nonparametric median tests for continuous variables and chi-squared tests for categorical variables assessed for differences for patient age, race, gender, insurance type, visit type, and provider gender. The institutional review board approved the study as exempt.

RESULTS

Patients (n = 12,619; median = 15 years; 58% female) were seen in primary care clinic. Providers asked about contraception for 82% of visits, and averaged 3 visits before contraception was discussed. For patients asked about contraception, 60% were using a contraceptive method, 15% left the visit on a new method (24.9% long-acting reversible contraception [LARC]). For patients not using contraception, 39.9% left the visit on a method. Patients asked about contraception were female, older, Hispanic, had public insurance, and were seen by female providers (P < .001). Follow-up/sick visits represented <20% of patients asked about contraception.

CONCLUSIONS

Multiple visits occur before contraception is discussed in adolescent primary care, and factors including age, race, and gender affect these discussions. Strategies to increase contraception discussions at all visits is essential, as adolescents do not always present for yearly visits.

Effects of clinic-level implementation of One Key Question® on reproductive health counseling and patient satisfaction

OBJECTIVE

We evaluated the effect of clinic level implementation of the One Key Question (OKQ) intervention, including physician and staff training and workflow adjustments, on reproductive counseling and patient satisfaction in primary care and ob/gyn.

STUDY DESIGN

We implemented the OKQ intervention in one primary care and one ob/gyn practice, while observing another primary care and ob/gyn practice that each provided usual care (control practices). We surveyed separate patient cohorts at two time points: 26 before and 33 after the primary care practice implemented OKQ, 38 before and 36 after the ob/gyn practice implemented OKQ, 26 and 37 at the primary care control practice, and 31 and 37 at the ob/gyn control practice. We used chi square tests to assess OKQ's effects on counseling rates and patient satisfaction, comparing intervention to control practices across time points.

RESULTS

In primary care, from before to after implementation, the intervention practice did not significantly increase reproductive counseling (69-76%, p = 0.58), but increased patient satisfaction (81-97%, p = 0.04) while the control practice demonstrated a decrease in patient satisfaction over the same time periods. In the ob/gyn clinics, no significant change in reproductive counseling or patient satisfaction was seen in the intervention practice, while the control practice demonstrated a decrease in patient satisfaction.

CONCLUSIONS

Implementing OKQ appears to increase patient satisfaction. Larger studies are needed to assess whether this clinic-level intervention may increase reproductive counseling.

IMPLICATIONS

Further studies of the impact of clinic-level implementation of OKQ are needed.

Rheumatology-led pregnancy clinic: enhancing the care of women with rheumatic diseases during pregnancy

The autoimmune rheumatic diseases have a clear predilection for women. Consequently, issues regarding family planning and pregnancy are a vital component of the management of these patients. Not only does pregnancy by itself causes physiologic/immunologic changes that impact disease activity but also women living with inflammatory arthritic conditions face the additional challenges of reduced fecundity and worsened pregnancy outcomes. Many women struggle to find adequate information to guide them on pregnancy planning, lactation and early parenting in relation to their chronic condition. This article discusses the gaps in the care provided to women living with inflammatory arthritis in standard practice and how a rheumatology nurse-led pregnancy clinic would fill such gap, consequently enhance the care provided and ensure appropriate education is provided to these individuals who represent the majority of the patients attending the rheumatology outpatient clinics. Such specialist care is expected to cover the whole journey as it is expected to provide high-quality care before, during and after pregnancy.

Perspectives of Adult Rheumatologists Regarding Family Planning Counseling and Care: A Qualitative Study

OBJECTIVE

Little is known about whether and how rheumatologists provide family planning counseling and reproductive health care (FPCC) to reproductive-age women with rheumatic diseases. This qualitative study sought to assess rheumatologists' perspectives, attitudes, and practices regarding FPCC.

METHODS

Semistructured interviews were conducted with a geographically diverse US sample of rheumatologists (n = 12). Interviews were transcribed verbatim, and a code book was inductively developed based on transcript content. Two coders applied the code book to all transcripts, and coding differences were adjudicated to full agreement. The finalized coding was used to conduct a thematic analysis.

RESULTS

Six themes were identified across interviews. Rheumatologists said that they 1) feel responsible for providing some FPCC to patients, 2) experience tension between respecting patients' autonomy and their own anxieties about managing high-risk pregnancies, 3) view patient-initiated conversations as FPCC facilitators, and they regard lack of guidelines and the presence of competing clinical priorities as barriers to FPCC, 4) are reluctant to prescribe contraception, 5) desire greater access to resources to help guide FPCC, and 6) recognize the benefits of multidisciplinary collaboration with gynecologists.

CONCLUSION

Rheumatologists feel a sense of responsibility to provide some aspects of FPCC to reproductive-age female patients. However, their own apprehensions about managing complicated pregnancies may negatively influence how they advise patients about pregnancy planning or avoidance. Rheumatologists do not prescribe contraception but rarely refer patients to gynecologists for contraceptive care. Future work should focus on eliminating barriers and identifying solutions that support rheumatologists' efforts to provide high-quality FPCC to patients.

Increase in Contraceptive Counseling by Primary Care Clinicians After Implementation of One Key Question® at an Urban Community Health Center

Introduction To provide quality family planning services and reduce racial and socioeconomic disparities in unintended pregnancy and pregnancy outcomes, primary care clinicians should routinely assess women's reproductive health needs and provide patient-centered contraceptive and preconception counseling. One Key Question® asks women if they would like to become pregnant in the next year and prompts clinicians to provide counseling appropriate to each patient. We conducted a pilot study to assess if implementing One Key Question® in the Electronic Medical Record (EMR) of an urban community health center, coupled with brief clinician training, would increase rates of contraceptive and preconception counseling. Methods We incorporated One Key Question® into a new EMR form and provided a brief training to primary care clinicians on reproductive life plan assessment, preconception counseling, and contraception. We surveyed women patients, ages 18-49, after their visit and compared pre- vsersus post-intervention rates of patient-reported contraceptive and preconception counseling. Results After One Key Question® was introduced in the clinic EMR and clinicians underwent brief training on its use, patients reported significantly higher rates of their clinician counseling them about contraception (52% vs. 76%, p = 0.040) and recommending a long-acting reversible contraceptive (LARC) method (10% vs. 32%, p = 0.035). There were no significant changes in preconception counseling. Discussion After EMR integration of One Key Question® coupled with brief clinician training, rates of contraceptive counseling and LARC recommendations increased in this community health center pilot study. Future research should compare One Key Question® to standard care in a prospective randomized trial.

Primary care providers' responses to pregnancy intention screening challenges: community-based participatory research at an urban community health centre

BACKGROUND

Incorporating pregnancy intention screening into primary care to address unmet preconception and contraception needs may improve delivery of family planning services. A notable research gap exists regarding providers' experiences conducting this screening in primary care.

OBJECTIVE

To explore primary care providers' perceived challenges in conducting pregnancy intention screening with women of reproductive age and to identify strategies to discuss this in primary care settings.

METHODS

This qualitative study emerged from a 2017 community-based participatory research project. We conducted semi-structured, in-depth interviews with 10 primary care providers who care for women of reproductive age at an urban federally qualified health centre. Analysis consisted of interview debriefing, transcript coding and content analysis with the Community Advisory Board.

RESULTS

Across departments, respondents acknowledged difficulties conducting pregnancy intention screening and identified strategies for working with patients' individual readiness to discuss pregnancy intention. Strategies included: linking patients' health concerns with sexual and reproductive health, applying a shared decision-making model to all patient-provider interactions, practicing goal setting and motivational interviewing, fostering non-judgmental relationships and introducing pregnancy intention in one visit but following up at later times when more relevant for patients.

CONCLUSIONS

Opportunities exist for health centres to address pregnancy intention screening challenges, such as implementing routine screening and waiting room tools to foster provider and patient agency and sharing best practices with providers across departments by facilitating comprehensive training and periodic check-ins. Exploring providers' experiences may assist health centres in improving pregnancy intention screening in the primary care setting.

Understanding Barriers to Contraception Screening and Referral in Female Adolescents and Young Adults with Cancer

Background: Contraception screening and referral occur infrequently in cancer care for young women of reproductive age. Barriers to contraception screening and referral in this setting have not been thoroughly identified. Objectives: We sought to understand oncology clinicians' current practices and perceptions of barriers to screening and referring young women for adequate contraception during cancer treatment. Methods: We conducted individual semi-structured interviews with 19 oncology clinicians whom we recruited from an urban, northeast medical center. Participants included physicians, advanced practice clinicians, and nurses in surgical and medical oncology. The interview guide addressed core components of the Promoting Action on Research Implementation in Health Services framework, and subsequent directed content analysis identified themes indicative of barriers to contraception screening and referral. Findings: Participants varied significantly in their current contraception screening practices; many conflated early pregnancy diagnosis or pregnancy avoidance counseling with contraception, whereas others described inaccurate contraceptive recommendations for specific clinical scenarios. Participants also lacked clarity of roles and responsibilities within the oncologic care team for contraception and assumed that another team member had addressed contraception. Participants perceived themselves to lack adequate education about contraception, which precluded contraception discussions. Conclusion: We recommend cancer centers consider these possible barriers to contraception screening and referral by promoting development of institutional guidelines to standardize contraception screening and referral, clarifying roles and responsibilities for contraception discussions within the care team, and expanding oncology clinician education on contraception. National professional organizations should work to expand guidelines to inform and support this process in clinical practice.