Prescription Birth Control Access Among U.S. Women at Risk of Unintended Pregnancy

Feasibility of a contraceptive-specific electronic health record system to promote the adoption of pharmacist-prescribed contraceptive services in community pharmacies in the United States

Objectives

Pharmacists in over half of the United States can prescribe contraceptives; however, low pharmacist adoption has impeded the full realization of potential public health benefits. Many barriers to adoption may be addressed by leveraging an electronic health records (EHR) system with clinical decision support tools and workflow automation. We conducted a feasibility study to determine if utilizing a contraceptive-specific EHR could improve potential barriers to the implementation of pharmacist-prescribed contraceptive services.

Materials and Methods

20 pharmacists each performed two standardized patient encounter simulations: one on the EHR and one on the current standard of care paper-based workflow. A crossover study design was utilized, with each pharmacist performing encounters on both standardized patients with the modality order randomized. Encounters were timed, contraceptive outputs were recorded, and the pharmacists completed externally validated workload and usability surveys after each encounter, and a Perception, Attitude, and Satisfaction survey created by the research team after the final encounter.

Results

Pharmacists were more likely to identify contraceptive ineligibility using the EHR-based workflow compared to the paper workflow (P = .003). Contraceptive encounter time was not significantly different between the 2 modalities (P = .280). Pharmacists reported lower mental demand (P = .003) and greater perceived usefulness (P = .029) with the EHR-based workflow compared to the paper modality.

Discussion and Conclusion

Pharmacist performance and acceptance of contraceptive services delivery were improved with the EHR workflow. Pharmacist-specific contraceptive EHR workflows show potential to improve pharmacist adoption and provision of appropriate contraceptive care.

The Effect of Social Media Influencer Warranting Cues on Intentions to Use Non-Hormonal Contraception

Young women increasingly get sexual health information from social media influencers, who use persuasive communication and can alter attitudes, intentions, and behaviors. Contraception is a commonly discussed health topic among influencers on social media. Previous research suggests that influencers negatively frame and encourage the discontinuation of hormonal contraception. At the same time, influencers also encourage the uptake of less effective non-hormonal options, such as fertility awareness-based methods. Though descriptive content analysis work details these patterns in influencer contraceptive messaging, there is no experimental research that explains message effects. The purpose of this study was to experimentally test the effect of influencer contraceptive-related messaging on behavioral health intentions. This study introduces warranting theory as a potentially valuable model for explaining online health communication message effects. Specifically, this study tested the effect of influencer messages containing sponsorship and medical disclaimers on intentions to use non-hormonal contraception. U.S. females (n = 296) ranging in age from 18-29 years old participated in a survey. Findings suggest that the interaction led to decreased intentions to use non-hormonal contraception. However, findings did not support a relationship between influencer messaging and impressions, which highlights potential boundary conditions for warranting theory and high-risk health behaviors. Additionally, there was a positive relationship between perceived trustworthiness and expertise of the influencer and intention to use non-hormonal contraception. Future research should test influencer messaging using real social media content and consider the effect of parasocial relationships. Practical implications highlight the need for comprehensive contraceptive counseling.

Skin tone discrimination and birth control avoidance among women in Harris County, Texas: a cross-sectional study

INTRODUCTION

Structural racism plays a major role in reproductive health inequities. Colorism, discrimination based on skin color, may profoundly impact reproductive health access and service delivery. However, quantitative research in this area is limited.

METHODS

We administered an online survey of women (n = 1,299) aged 18-44 from Harris County, Texas to assess the relationship between skin color discrimination and reproductive health service avoidance. The survey included questions on demographics, self-reported skin tone, and dichotomous measures of previous discrimination experiences and avoidance of care because of perceived discrimination. Binary logistic regression was used to examine whether race/ethnicity, skin tone, and previous discrimination experiences were related to avoidance of contraceptive care because of perceived discrimination.

RESULTS

Approximately one-third (31.5%) of the sample classified themselves as non-Hispanic Whites (31.5%), 22.4% as Black, 27.4% as Hispanic and born within the US, and 7.6% as Hispanic born outside of the US. Approximately one-third of women classified themselves in the lightest skin tones, whereas almost one in five women classified themselves in the darkest skin tone palates. Darker skin tones had increasingly greater odds of reporting that they avoided seeking birth control out of a concern for discrimination compared to the lightest skin tone. After adjusting for race/ethnicity and sociodemographic variables (model 3), darker skin tones remained significantly associated with avoiding birth control.

DISCUSSION

This study demonstrates the role that skin color discrimination plays in negative reproductive health experiences. While this is not surprising given that those with racist ideologies developed the concept of these racial and ethnic categories, the apparent association with darker skin colors and avoidance of seeking birth control provides evidence that structural and individual racism continues to have far-reaching and insidious consequences.

CONCLUSION

Contraception is recognized for reducing maternal mortality, improving child health, increasing female empowerment, and decreasing poverty. However, not all women equally enjoy the benefits of access to contraception. Addressing colorism within reproductive healthcare has become critically important as the nation becomes increasingly diverse. Focusing on skin tone-based discrimination and its roots in anti-blackness expands our understanding beyond a Black-White binary traditionally applied when addressing racism in healthcare delivery.

Approval of the First Nonprescription Oral Contraceptive Pill

In July 2023, the U.S. Food and Drug Administration approved Opill (norgestrel 0.075 mg), a progestin-only tablet to prevent pregnancy to be used without a prescription. Although progestin-only birth control pills were approved in 1973, it has taken 50 years for the first oral contraceptive pills to be sold over the counter. In this column, I review the evidence on the barriers to access oral contraceptive pills, the efficacy, preferences and support of a nonprescription progestin-only pill, the cost, and policy implications for health insurance coverage. I conclude with recommendations from professional organizations on over-the-counter access to hormonal contraception.

Over-the-counter access to hormonal contraception: a global perspective

PURPOSE OF REVIEW

Oral contraceptive pills are among the most popular contraceptives worldwide, including among adolescents, and are available over the counter in over 100 countries. However, when a prescription is required, oral contraceptives may be difficult to obtain, particularly for adolescents. Recent approvals of over-the-counter progestin-only pills in the United Kingdom and United States have brought widespread attention to this topic.

RECENT FINDINGS

Progestin-only pills, including the norgestrel pill recently approved for over-the-counter use in the United States, are highly effective and may be used safely without a prescription or medical monitoring, including by adolescents. These pills are associated with relatively high user satisfaction. Although over-the-counter availability may improve contraceptive access overall, issues related to insurance coverage and out-of-pocket cost may continue to pose practical barriers to access for many individuals.

SUMMARY

Over-the-counter oral contraceptives are an appropriate and important contraceptive option for many adolescents. Over-the-counter availability has the potential to increase access to safe and effective contraception in the United States, United Kingdom, and other countries where a prescription is currently required. Future research on use patterns among adolescents is needed, as are advocacy efforts and policies to ensure access and affordability.

Racial Disparities in Highly Effective Contraceptive Use Among U.S. Active Duty Servicewomen, Fiscal Years 2016-2019

Background: Previous studies have found that unintended pregnancy rates are higher among racial minorities and active duty servicewomen (ADSW), correlating with lower rates of effective contraceptive use. The Military Health System (MHS) provides universal health care benefit coverage for all ADSW, including access to all highly effective contraceptive (HEC) methods. This study investigated the association between race and HEC use among ADSW. Materials and Methods: We conducted a cross-sectional study using fiscal year 2016-2019 data from the MHS Data Repository for all ADSW ages 18-45 years. Statistical analyses included descriptive statistics and logistic regression models, adjusted and unadjusted, determining the odds of HEC use, overall and by method. Results: Of the 729,722 ADSW included in the study, 59.7% used at least one HEC during the study period. The highest proportions of users were aged 20-24 years, White, single, Junior Enlisted, and serving in the Army. Lower odds of HEC use were demonstrated in Black (odds ratio [OR] = 0.94, 95% confidence interval [CI] = 0.92-0.95), American Indian/Alaska Native (OR = 0.85, 95% CI = 0.82-0.89), Asian/Pacific Islander (OR = 0.81, 95% CI = 0.80-0.83), and Other (OR = 0.97, 95% CI = 0.94-0.99) ADSW compared with White ADSW. Conclusions: Universal coverage of this optional preventive service did not guarantee its use. The MHS can serve as a model for monitoring racial disparities in HEC use.

Implementation of pharmacist-prescribed contraceptive services: A case series of early adopters

Background

The objective of this study was to interview five early adopters of pharmacist-prescribed contraceptive services to gain insight into successful implementation, with a focus on each pharmacy's approach, successes, challenges, lessons learned, and practice implications.

Case Summaries

The five pharmacists who were interviewed included men and women working for independent, chain, and hospital system pharmacies in rural, suburban, and urban areas in various states. Each pharmacy had a unique approach to implementation of pharmacist-prescribed contraceptive services and a variety of service features. The pharmacists were asked about their motivation for starting the service, implementation processes, financial justification, challenges, and successes. Similarities and differences in the intervention characteristics (processes), outer setting (factors outside of the pharmacy), inner setting (factors within the pharmacy), and individual characteristics were compared to determine lessons learned and practice implications for implementation of pharmacist-prescribed contraceptive services.

Practice Implications

The pharmacists interviewed encountered common challenges in implementing pharmacist-prescribed contraception services, including lack of community awareness, difficulty justifying the service financially, difficulty with time management, staying updated with changing regulations, and managing staff turnover. Successful contraception service implementation strategies included efficient workflow integration, financial justification of the service, and increasing community awareness of the service.

Conclusion

These early adopter case studies can serve as a reference for pharmacists wanting to implement contraceptive services in their pharmacies. By incorporating lessons learned and anticipating challenges, more pharmacies may be able to offer contraceptive services, further increasing patient access to contraceptives.

Opill: The Over-the-Counter Contraceptive Pill

The U.S. Food and Drug Administration has approved the first oral contraceptive pill (OCP) for over-the-counter status. This progestin-only pill contains norgestrel 0.075 mg taken daily, with a Pearl Index estimated at 4.4 (95% CI, 1.9-8.8). This formulation has an excellent safety profile, with current breast cancer as the only absolute contraindication and few relative contraindications. Ultimately, this approval has great potential to improve the accessibility of effective contraception for many pregnancy-capable Americans, especially those who have poor access to the health care system for prescription-required contraception, most notably people who hold marginalized identities. The pill's overall success in reducing rates of unintended pregnancy will rely on its availability, particularly in rural communities that may rely on one pharmacy, and affordability, especially for uninsured or underinsured individuals. However, given the need for improved contraceptive provision, particularly in abortion-restrictive settings, the over-the-counter approval of this daily OCP is a major advancement in the nation's contraceptive ecosystem.

Implementation of pharmacy access to hormonal contraception

BACKGROUND

States throughout the country are enacting legislation to authorize pharmacist prescribing of hormonal contraception to decrease barriers to access. Little is known about the process of state implementation of pharmacist prescriptive authority for hormonal contraception.

OBJECTIVES

To understand the state-level steps to enable pharmacist prescribing of hormonal contraception, including implementation challenges and facilitators.

METHODS

We conducted a qualitative study of interviews with 18 key individuals, including pharmacists and other stakeholders, from ten states with laws permitting pharmacist-prescribed hormonal contraception from March 2021 to April 2022. We analyzed data using directed qualitative analysis principles and compared experiences across states. We organized the data using the Consolidated Framework for Implementation Research framework and evaluated relevant constructs in states' implementation efforts.

RESULTS

Participants identified four key steps to implement pharmacist prescribing at the state level, including development of state rules and regulations, educational programs, reimbursement mechanisms, and expansion strategies to pharmacists and pharmacies. Participants identified early involvement of key stakeholders and a culture of support for clinical pharmacists as facilitators to implementation. Challenges included complexity and cost of billing mechanisms, lack of funding for implementation efforts, and competing priorities of pharmacies/pharmacists.

CONCLUSION

Participants in states with pharmacist prescriptive authority for hormonal contraception identified development of reimbursement and billing mechanisms as the most critical state-level step in implementation. Focusing on facilitators of key steps can guide states in developing successful implementation strategies to improve contraceptive access.

Access to on-campus contraception on college and university campuses in North Carolina

BACKGROUND AND OBJECTIVE

Unintended pregnancies occur more frequently in college students and negatively affect health outcomes and educational attainment. This study examined access to on-campus contraceptives at all 4-year colleges and universities in North Carolina (NC).

METHODS

This institutional review board-exempt study evaluated availability of on-campus contraceptives including condoms; hormonal contraceptives including pills, patches, and vaginal rings; medroxyprogesterone injections; implants; intrauterine devices; and emergency contraception via website review. Institutions were stratified by characteristics including size, location, type (e.g., public, private, religious affiliation, historically black colleges and universities, women's colleges), and presence of a student health pharmacy. Comparisons were made using chi-square test or Fisher's exact test.

RESULTS

Fifty-four 4-year colleges and universities were identified. A plurality or the majority of schools were considered small (41%) and urban (48%) and had a religious affiliation (61%). Thirty-three percent of colleges and universities had an on-campus pharmacy. The most frequent contraceptives offered were condoms (43%), oral contraceptives (33%), and medroxyprogesterone injections (22%). Emergency contraception was available at approximately one-third of colleges and universities. Six percent of institutions provided a full range of contraceptive methods. Contraceptives were offered more frequently at large, public, urban institutions, whereas religious institutions and smaller institutions were less likely to offer contraceptives.

CONCLUSION

Access to on-campus contraception for college students in NC is lacking, and the vast majority of institutions did not provide a full range of contraceptives. Policy measures, such as enhancing reproductive health services at student health centers or increasing contraception availability directly through pharmacies, are needed to improve access for college students.

Reproductive decision making in women with medical comorbidities: a qualitative study

BACKGROUND

A growing number of reproductive-age women in the U.S. have chronic medical conditions, increasing their risk of perinatal morbidity and mortality. Still, they experience unintended pregnancies at similar rates to low-risk mothers. We have limited understanding of how these individuals consider decisions about pregnancy and contraceptive use. The purpose of this study was to understand factors that influence reproductive decision-making among pregnant women with chronic medical conditions.

METHODS

We conducted 28 semi-structured interviews with pregnant women with pre-existing medical conditions admitted to a tertiary maternal hospital to examine factors influencing reproductive decision making. Maternal demographic characteristics, medical history, and pregnancy outcome data were obtained through participant surveys and abstraction from electronic health records. Interview transcripts were coded and analyzed using Dedoose® with both deductive and inductive content analysis.

RESULTS

Out of 33 eligible participants, 30 consented to participate and 28 completed interviews. The majority of participants identified as black, Christian, made less than $23,000 yearly, and had a variety of preexisting medical conditions. Overarching themes included: 1) Perceived risks-benefits of pregnancy, 2) Perceived risks-benefits of birth control, 3) Determinants of contraceptive utilization, and 4) Perceived reproductive self-agency. Contraception was viewed as acceptable, but with concerning physical and psychological side effects. Although some considered pregnancy as a health threat, more experienced pregnancy as positive and empowering. Few planned their pregnancies.

CONCLUSIONS

Preexisting health conditions did not significantly influence reproductive decision-making. Barriers to birth control use were generally based in patient value-systems instead of external factors. Interventions to improve uptake and use of birth control in this cohort should focus on improving care for chronic health conditions and influencing patient knowledge and attitudes toward contraception.

South Carolina's Medicaid Expansion: An Unsolved Problem for Vulnerable Populations

South Carolina is home to millions of residents and is renowned for its subtropical climate and beautiful beaches. Nevertheless, the state's healthcare system faces significant challenges, with a ranking in the bottom 50% of all states, a statistic that warrants serious attention. One of the most pressing healthcare issues in South Carolina is accessibility. The state currently has a higher percentage of its population that is medically uninsured compared to the national average in the United States (18% vs 14%, respectively). Consequently, a lower proportion of South Carolinians enjoy access to healthcare services when compared to residents of other states. Unfortunately, recent efforts to expand coverage for more of its residents via the Medicaid expansion by the Affordable Care Act (ACA) have been opposed by legislation. Lack of accessible healthcare is a significant issue in this state and the state legislature should increase access, especially to low-income vulnerable populations.

Over-the-Counter Oral Contraception as an Opportunity to Reduce Contraceptive Access Inequity

This Viewpoint argues that making a progestin-only contraceptive pill available for sale as an over-the-counter product will help reduce logistic barriers to safe and effective birth control.

Experiences of progestin-only pill users in the United States and attitudes toward over-the-counter access

CONTEXT

Removing the prescription requirement and making oral contraceptive pills available over the counter (OTC) could increase contraceptive access in the United States. Despite current efforts to make a progestin-only pill (POP) available OTC, there are no qualitative data exploring the experiences of POP users and their perspectives on making POPs available OTC.

METHODS

We conducted six online, asynchronous focus group discussions with 36 POP users between July and November 2020. We stratified focus group discussion placement based on three reasons for POP use: breastfeeding, having a contraindication to estrogen (for a reason other than breastfeeding), and for any other reason. We thematically analyzed these data using inductive and deductive coding.

RESULTS

The majority of participants described their overall POP experience as positive, mostly because they experienced minor or no side effects and thought the pill was effective. Participants overwhelmingly supported OTC availability of POPs and expressed interest in purchasing an OTC POP. Over one-third of participants had very limited knowledge or held inaccurate assumptions about POPs before they started using this method and many stressed the need to disseminate accurate information and resources about POPs to the public.

CONCLUSIONS

Most focus group discussion participants were satisfied with POPs and supported OTC access. While misconceptions and concerns about POPs should be addressed, an OTC POP has the potential to be a safe, effective, and convenient contraceptive option in the United States.

Challenges accessing contraceptive care and interest in over-the-counter oral contraceptive pill use among Black, Indigenous, and people of color: An online cross-sectional survey

OBJECTIVE

To examine challenges accessing contraception in the past year and their association with interest in using an over the counter (OTC) oral contraceptive pill (OCP) among Black, Indigenous, and people of color (BIPOC) in the United States.

STUDY DESIGN

From May 2021 to March 2022, a collaborative research team conducted a cross-sectional online survey using convenience sampling to recruit people who identify as Asian American, Native Hawaiian, or Pacific Islander, Black or African American, Indigenous, or Latina/Latinx and used or wanted to use a contraceptive method in the past year. Respondents were recruited through reproductive justice and community-based organizations.

RESULTS

Among 727 respondents, 45% reported experiencing at least one challenge accessing contraception in the past year of which 37% reported a logistical challenge, and 20% reported an interpersonal challenge. Sixty-seven percent of respondents said they were likely to use an OTC OCP. Respondents who reported experiencing at least one challenge accessing contraception in the past year were more likely to say they would use an OTC OCP. Fifty-seven percent of respondents who were not using a contraceptive method in the past year reported they were likely to use an OTC OCP.

CONCLUSION

Among people in this study, interest in an OTC OCP is high, particularly among those who have faced challenges accessing contraception, and among those who are not currently using a contraceptive method.

IMPLICATIONS

Availability of an OCP OTC has the potential to address challenges accessing contraceptive care among BIPOC in the United States, who are often impacted by structural inequities and racism. Findings from this study can inform future OTC implementation strategies to ensure OTC access addresses logistical and interpersonal challenges.

Pilot label comprehension study for an over-the-counter combined oral contraceptive pill in the United States

CONTEXT

A growing body of evidence supports over-the-counter access to oral contraceptives in the United States. An important consideration for over-the-counter approval is consumers' ability to understand key package label messages related to safety and effectiveness without clinician involvement. We developed a prototype over-the-counter Drug Facts Label for a combined oral contraceptive pill and conducted a pilot label comprehension study to evaluate consumer understanding of key messages for use.

METHODS

In November-December 2020, we conducted interviews with 163 adults and teens in the United States who were aged 12-49 years and identified as female or another gender but had a uterus and the ability to become pregnant. We developed 11 primary endpoints based on assessment of clinical risks that could occur if consumers fail to heed them, including messages about contraindications and directions for use; 11 secondary endpoints represented additional important information but with lower potential for clinical consequences if not understood. We evaluated endpoint comprehension by computing frequencies, percentages, and 2-sided Exact (Clopper-Pearson) 95% confidence intervals for observed proportions.

RESULTS

Ten of the 11 primary endpoints and 10 of the 11 secondary endpoints were each understood by ≥95% of participants. The remaining primary endpoint on use with prior blood clots was understood by 89% of participants. The remaining secondary endpoint on the product being designed for "people who have the ability to become pregnant" was understood by 83% of participants.

CONCLUSION

Participants understood the key label information required for safe and effective combined oral contraceptive use without clinician involvement.

Effectiveness and efficacy rates of progestin-only pills: A comprehensive literature review

OBJECTIVES

To synthesize published literature on POP effectiveness and efficacy.

STUDY DESIGN

We searched PubMed Central, PubMed, and the Cochrane library through March 07, 2022. We included articles written in English reporting a Pearl Index or life table rate for pregnancy. We excluded articles only assessing formulations that: were never marketed globally, are only sold in combination with estrogen, are currently sold only for noncontraceptive purposes, or were not given to participants continuously. Four researchers independently extracted data and two analyzed data using Excel and R.

RESULTS

We included 54 studies. Among studies at low or moderate risk of bias, the median Pearl Index rate (the failure rate during typical use) was 1.63 (range 0.00-14.20, IQR 4.03) and the median method failure Pearl Index rate (the failure rate during perfect use) was 0.97 (range 0.40-6.50, IQR 0.68). Excluding the newer formulations, Desogestrel and Drospirenone, which are closer to combined oral contraceptives in that they prevent pregnancy by inhibiting ovulation, the median Pearl Index rate is 2.00 (range 0.00-14.12, IQR 2.5) and the median method failure Pearl Index rate is 1.05 (range 0.00-10.90, IQR 1.38).

CONCLUSIONS

Among studies at low or moderate risk of bias, the median Pearl Index rate during typical POP use was much lower than currently estimated (7.00), while the median perfect use rate was similar to current estimates.

IMPLICATIONS

Future research should investigate the possibility that POPs may be much more effective during typical use than currently believed.

Who Accesses Birth Control Online? An Analysis of Requests for Contraception Submitted to an Online Prescribing Platform in the United States

INTRODUCTION

Telehealth has the potential to increase contraceptive access. Little is known about the characteristics of people using online prescribing platforms or whether these services help fill access gaps.

METHODS

We analyzed requests for contraception submitted between July 2015 and September 2017 to an online prescribing platform that offers sexual and reproductive care in the United States. We analyzed the characteristics of people seeking contraceptives, prevalence of contraindications to hormonal contraception among contraceptive seekers, and extent to which online prescribing may close contraceptive access gaps.

RESULTS

A total of 38,439 requests for prescription hormonal birth control were received during the study period, with requests increasing dramatically over this timeframe as the platform expanded operations to an increasing number of states. Methods were dispensed in response to 63% of requests. In this population seeking contraception, an estimated 1.2% had a contraindication to progestin-only pills, and an estimated 12.0% of patients who reported their blood pressure had a contraindication to combined hormonal methods. Few requests came from patients younger than 18 (1.2%). In multivariable negative binomial models, urban counties had a larger concentration of requests, whereas counties with higher rates of uninsurance and poverty had lower rates of requests.

CONCLUSIONS

Results suggest that the population seeking contraception from one online prescribing platform has similar levels of contraindications to hormonal contraceptives as found in prior research. Future research should seek to understand why utilization of this online prescribing platform was lower among young people, how to expand outreach to rural populations, and what underlies individuals' decisions about using these services.

Interest in Continued Use After Participation in a Study of Over-the-Counter Progestin-Only Pills in the United States

OBJECTIVE

To assess interest in continued use of over-the-counter progestin-only pills among individuals who used them in a trial.

METHODS

From January 2020 to September 2021, we conducted a cross-sectional online survey with individuals who completed participation in a trial evaluating over-the-counter use of norgestrel 0.075 mg tablets in the United States. We calculated descriptive statistics, Pearson's chi-square and Fisher's exact tests, and logistic regression models to assess likelihood of future over-the-counter progestin-only pill use, reasons for interest/noninterest, situations for over-the-counter progestin-only pill use, willingness to pay for an over-the-counter progestin-only pill, likelihood of future preventive health screenings, prior difficulties getting prescription contraception, and background characteristics.

RESULTS

Among 550 adult and 115 adolescent participants (75% response rate), 83% reported likelihood of future over-the-counter progestin-only pill use. Hispanic/Latinx and Black participants and adults with public insurance, prior pregnancies, and some college reported higher likelihood of future use compared with their counterparts. Among likely users, 90% were interested in long-term use and 79 % ≥ 25 years of age reported they would get future preventive screenings; participants would pay up to $20/month on average. Primary reasons for interest included convenience (81%), ease of access (80%), and saving time (77%) and money (64%). The primary reason for noninterest was bleeding associated with progestin-only pill use (52%).

CONCLUSION

There was high interest in continuing to use over-the-counter progestin-only pills among individuals who had used them in a study. These findings highlight the real-world acceptability of taking a progestin-only pill without a prescription, and contribute to evidence supporting over-the-counter access.

A Prospective Cohort Study of Changes in Access to Contraceptive Care and Use Two Years after Iowa Medicaid Coverage Restrictions at Abortion-Providing Facilities Went into Effect

Inequities in access to contraception based on ability to pay can interfere with individuals’ reproductive autonomy. This study examines the impact of a 2017 state-level policy in Iowa restricting Medicaid coverage at abortion-providing health care centers on patients’ access to contraceptive care and subsequent contraceptive use. We draw on a unique panel dataset of individuals who originally sought care at a publicly supported family planning site in Iowa in 2018–2019 and then participated in subsequent follow-up surveys every 6 months for 2 years to examine an effect of access to care on contraceptive use. Among our final analytic sample of 368 individuals, our findings indicate that receipt of recent contraceptive care decreased over the study period; this coincided with patients shifting away from getting contraceptive care at sites potentially impacted by the 2017 Iowa Medicaid policy restriction while those getting this care at non-impacted sites remained relatively steady over the study period. At the same time, nonuse of contraception increased while use of a contraceptive method that carries cost, use of a provider-involved method, and satisfaction with one’s method decreased. We find that, after controlling for patient characteristics, those who shifted toward receiving contraceptive care experienced increases in these three contraceptive outcomes. We interpret this as preliminary descriptive evidence demonstrating an impact of disruptions in access to contraceptive care on contraceptive outcomes. Supportive payment and funding strategies for contraception, rather than policies that impede or restrict access, are needed to enable people to realize full reproductive autonomy.

Understanding contraceptive failure: an analysis of qualitative narratives

Most American women wanting to avoid pregnancy use contraception, yet contraceptive failures are common. Guided by the Health Belief Model (HBM), we conducted a secondary qualitative analysis of interviews with women who described experiencing a contraceptive failure (n=69) to examine why and how this outcome occurs. We found three primary drivers of contraceptive failures (health literacy and beliefs, partners and relationships, and structural barriers), and we identified pathways through which these drivers led to contraceptive failures that resulted in pregnancy. These findings have implications for how individuals can be better supported to select their preferred contraception during clinical contraceptive discussions.

A systematic review of the qualitative literature on barriers to high-quality prenatal and postpartum care among low-income women

OBJECTIVE

To examine the qualitative literature on low-income women's perspectives on the barriers to high quality prenatal and postpartum care.

DATA SOURCES AND STUDY SETTING

We performed searches in PubMed, Web of Science, Embase, SocIndex, and CINAHL for peer-reviewed studies published between 1990 to 2021.

STUDY DESIGN

Systematic review of qualitative studies with participants who were currently pregnant or had delivered within the past two years and identified as low-income at delivery.

DATA COLLECTION / EXTRACTION METHODS

Two reviewers independently assessed studies for inclusion, evaluated study quality, and extracted information on study design and themes.

PRINCIPLE FINDINGS

We identified 34 studies that met inclusion criteria, including 23 focused on prenatal care, 6 on postpartum care, and 5 on both. The most frequently mentioned barriers to prenatal and postpartum care were structural. These included delays in gaining pregnancy-related Medicaid coverage, challenges finding providers who would accept Medicaid, lack of provider continuity, transportation and childcare hurdles, and legal system concerns. Individual-level factors, such as lack of awareness of pregnancy, denial of pregnancy, limited support, conflicting priorities, and indifference to pregnancy also interfered with timely use of prenatal and postpartum care. For those who accessed care, experiences of dismissal, discrimination, and disrespect related to race, insurance status, age, substance use, and language were common.

CONCLUSIONS

Over a period of 30 years, qualitative studies have identified consistent structural and individual barriers to high-quality prenatal and postpartum care. Medicaid policy changes including expanding presumptive eligibility, increased reimbursement rates for pregnancy services, payment for birth doula support, and extension of postpartum coverage may help overcome these challenges.

The Relationship between the Sexual Double Standard and Women's Sexual Health and Comfort

The current research explores the relationship between Sexual Double Standard (SDS) endorsement and women's sexual health and attitudes. Women (n = 705) completed an SDS endorsement scale, and then answered a variety of questions in three main categories of outcome variables: sexual comfort, sexual reputation, and sexual health. Results suggest that women's SDS endorsement was not related to women's sexual comfort. Further, SDS endorsement was slightly positively related to how concerned women were about their sexual reputation. Regarding sexual health, SDS endorsement was related to a shorter timespan since women's last OBGYN screening, and unrelated to women's discomfort discussing birth control with their OBGYN. Results suggest there is much more to explore in targeted studies on the relationship of SDS endorsement to women's perceptions of their sexual reputations and their interactions with OBGYNs with respect to the SDS. Previous and related research is discussed, along with implications of the current research.

North Carolina Pharmacists' Support for Hormonal Contraception Prescription Status Change

BACKGROUND

Pharmacist-prescribed hormonal contraception (HC) may offer additional avenues of access for patients; however, it is unknown whether pharmacists would support over-the-counter access to contraception over pharmacist-prescribed models.

OBJECTIVE

The objective of this study was to understand how North Carolina (NC) pharmacists believed HC should be classified and how pharmacist and pharmacy characteristics were associated with those beliefs.

METHODS

This study was a secondary analysis of a cross-sectional, anonymous, online survey completed by 587 licensed NC pharmacists. The primary outcome of interest was how pharmacists believed HC should be classified: prescription-only, pharmacist-prescribed, behind-the-counter, or over-the-counter. Multinomial bivariate and multivariable regression analyses were conducted to describe the association between pharmacist and pharmacy characteristics with the outcomes of interest through odds ratios and adjusted odds ratios, respectively. Chi-square tests were used to examine the association of geographic location with distribution of attitudes toward HC classification.

RESULTS

Fifty-one percent of NC pharmacists supported classification of HC as pharmacist-prescribed, while 23% supported non-prescription (behind- or over-the-counter) classification. Controlling for pharmacist demographics and pharmacy characteristics, completing residency training was significantly associated with supporting pharmacist-prescribed vs prescription-only classification (adjusted odds ratio (aOR) = 2.55, P = .02). Pharmacists had higher odds of supporting pharmacist-prescribed vs prescription-only HC if they agreed that they were well trained to do so (aOR = 3.14, P < .01). Distribution of attitudes about classification of HC did not significantly differ by geographic location (P = .14).

CONCLUSIONS

Most NC pharmacists support deviating from the current prescription-only classification of HC, with more support for pharmacist-prescribed classification. Continuing education programs should focus on training pharmacists to feel more confident prescribing HC.

Women Get Worse Sex: A Confound in the Explanation of Gender Differences in Sexuality

Gender differences in sexuality have gained considerable attention both within and outside of the scientific community. We argue that one of the main unacknowledged reasons for these differences is simply that women experience substantially worse sex than men do. Thus, in examinations of the etiology of gender differences in sexuality, a confound has largely been unacknowledged: Women and men are treated to different experiences of what is called "sexuality" and "having sex." We discuss four arenas in which women's experience of sexuality may often be worse than men's: (a) anatomical differences, (b) sexual violence, (c) stigma, and (d) masculine cultures of sexuality. Then we consider how each disparity might explain well-known gender differences in sexuality.

Patient experiences with pharmacist prescribed hormonal contraception in California independent and chain pharmacies

BACKGROUND

Pharmacist contraception care is an innovative practice that is rapidly expanding with policy changes. There is limited literature describing patient experiences with this pharmacist service.

OBJECTIVE

The objective of this study is to describe patient experiences using pharmacist-prescribed hormonal contraception in California pharmacies.

METHODS

An online survey was conducted among a cross-sectional convenience sample of people of all ages who completed a contraception visit with a pharmacist from December 2017 to January 2019 at a participating independent or chain pharmacy in California. Descriptive statistics were used to analyze data on patient characteristics, experiences and satisfaction with the service, and preventive health screenings.

RESULTS

A total of 160 individuals completed the survey and nearly all were adults (97%) and had started or completed postsecondary education (85%). Most (72%) visited the pharmacy to get a prescription for a contraceptive method they were already using. The most common method prescribed was the pill (90%). The most common reason for seeking a prescription at a pharmacy was because it would be faster than waiting for a doctor's appointment (74%), followed by the location and hours being more convenient (46% and 41%), saving money (28%), and not having a regular doctor (26%). Respondents reported satisfaction with the services overall (97%), level of comfort they felt with the pharmacist (94%), counseling provided (86%), and level of privacy (74%). Nearly all were likely to return to a pharmacist for contraception (96%) and recommend the service to a friend (95%).

CONCLUSION

Pharmacist prescribing of contraception in community pharmacies provided a convenient access point that was highly acceptable to patients who used it. One area for attention is in the level of privacy during contraception visits. These findings support the effectiveness of direct pharmacy access to contraception and encourage pharmacist contraception prescribing policies and widespread implementation.

Associations between adverse childhood experiences and contraceptive use among young adults in Honduras

OBJECTIVE

Research on adverse childhood experiences (ACEs) and use of modern contraception is limited in Honduras. The government has made substantial gains in promoting modern contraception. Young adults experience high rates of violence. The aim of this study was to assess the relationship between ACEs and contraceptive behaviors among young women and men.

METHODS

We used data from 810 women and 753 men aged 18-24 years from the 2017 Honduras Violence against Children Survey, a cross-sectional, nationally representative household survey of childhood adversity. We assessed associations between ACEs and three contraceptive use outcomes: use versus nonuse of modern contraceptives; use of methods requiring medium/high or low programmatic support among current contraceptive users; and frequent versus infrequent condom use.

FINDINGS

Exposure to physical or emotional abuse and witnessing violence in the home was not significantly associated with the three contraceptive use outcomes for men or women. Sexual abuse and parental separation reduced odds of contraceptive use among women (Odds Ratio (OR) < 0.60) but not among men. In contrast, orphan status increased odds of modern contraception use among men (OR 1.93) and frequent condom use among women (OR 2.22).

CONCLUSION

The inconsistent direction and magnitude of associations between ACEs and modern contraceptive use among young men and women suggests divergent relationships between ACEs and sexual and reproductive health behaviors. Results may highlight the strength of norms around contraceptive use and/or widespread access to community-based family planning programs and comprehensive sexuality education, irrespective of exposure to ACEs in Honduras.

Provider Perspectives of Barriers to Contraceptive Access and Use among Women with Substance Use Disorders

OBJECTIVES

Previous studies conducted from the patient perspective indicate that women with substance use disorders (SUDs) experience extensive barriers to contraceptive access and use (CAU), but there is limited research investigating this topic from the provider perspective. We explored provider perspectives on the barriers to CAU for women with SUDs. As a secondary objective, we highlighted provider contraceptive counseling strategies to address patient CAU barriers.

METHODS

We conducted 24 qualitative interviews with a purposeful sample of women's health providers, including medical doctors, nurse practitioners, and certified nurse-midwives. We used thematic analysis to code the interviews with inductive codes and organized findings according to levels of influence within the Dahlgren and Whitehead rainbow model, a socioecological model of health.

RESULTS

Provider-reported barriers to CAU were identified at four levels of socioecological influence and included reproductive misconceptions; active substance use; trauma, interpersonal violence, and reproductive coercion; limited social support; lack of housing, employment, health insurance, and transportation; stigma; discrimination; and punitive prenatal substance use policies and child welfare reporting requirements. Strategies for addressing CAU barriers mainly focused on patient-centered communication, including open information exchange, shared decision-making, and relationship building. However, providers described disproportionately highlighting the benefits of long-acting reversible contraception (LARC) and directing conversations toward LARC when they perceived that such methods would help patients to overcome adherence and other challenges related to active substance use or logistical barriers. Notably, there was no mention of CAU facilitators during the interviews.

CONCLUSIONS

Providers perceived that women with SUDs experience a range of CAU barriers, which they addressed within the clinical setting through use of both patient-centered communication and highlighting the benefits of LARC when they perceived that such methods would help clients to overcome barriers. Improving CAU for women with SUDs will require multidisciplinary, multipronged strategies that prioritize reproductive autonomy and are implemented across clinical, community, and policy settings.

Accessibility of Pharmacist-Prescribed Contraceptives in Utah

OBJECTIVE

To assess pharmacy participation in and accessibility of pharmacist-prescribed contraception after legislation effective in the state of Utah in 2019.

METHODS

A secret-shopper telephone survey was used to assess participation in pharmacist-prescribed contraception. Geospatial analysis was used to map the distribution of participating pharmacies by population characteristics.

RESULTS

Of all operating Class A retail pharmacies in Utah, 127 (27%) were providing pharmacist-prescribed contraception 1 year after implementation of the Utah standing order. Oral contraceptive pills were widely accessible (100%); however, other allowed methods were not (vaginal ring 14%; contraceptive patch 2%). Consultation fees and medication costs varied widely. Participating pharmacies were mainly concentrated in population centers. Assuming access to a personal vehicle, urban areas with a high percentage of Hispanic people (Utah's largest minority race or ethnicity group) have access to a participating pharmacy within a 20-minute driving distance. However, access in rural areas with a high percentage Hispanic or other minority were limited. We identified 235 (40%) census tracts with a high proportion of Utah's residents living below the poverty line or of minority race or ethnicity who also had low access to pharmacist-prescribed contraception.

CONCLUSIONS

Although the pharmacy-based model is intended to increase access to contraception, practical availability 1 year after the authorization of pharmacist-prescribed contraception in Utah suggests that this service does not adequately serve rural areas, particularly rural areas with a high proportion of minorities and those living below the federal poverty line.

Contraceptive Care Disparities Among Sexual Orientation Identity and Racial/Ethnic Subgroups of U.S. Women: A National Probability Sample Study

Background: Sexual minority women may use contraception for various reasons but face notable barriers to contraceptive care, including stigma and discrimination. However, studies examining sexual orientation disparities in contraceptive care have largely relied on nonprobability samples of predominately White women and may thus not be generalizable to U.S. women overall or Black and Latina women in particular. Materials and Methods: Using data from the 2006 to 2017 National Survey of Family Growth, a large national probability sample of U.S. women 15-44 years of age (N = 25,473), we used multivariable logistic regression to estimate adjusted odds ratios for receiving a contraceptive method or prescription and contraceptive counseling from a health care provider in the past year among sexual orientation identity and racial/ethnic subgroups of heterosexual, bisexual, and lesbian White, Black, and Latina women relative to White heterosexual women. Results: Among women overall, 33.9% had received contraception and 18.3% had obtained contraceptive counseling. Black (odds ratio [OR] = 0.73, 95% confidence interval [CI]: 0.65-0.82) and Latina (OR = 0.73, 95% CI: 0.64-0.82) heterosexual women, White (OR = 0.80, 95% CI: 0.65-0.99) and Black (OR = 0.43, 95% CI: 0.32-0.58) bisexual women, and White (OR = 0.23, 95% CI: 0.13-0.43), Black (OR = 0.19, 95% CI: 0.09-0.40), and Latina (OR = 0.08, 95% CI: 0.03-0.22) lesbian women had significantly lower adjusted odds of receiving contraception compared with White heterosexual women. White (OR = 0.36, 95% CI: 0.15-0.85), Black (OR = 0.42, 95% CI: 0.18-0.98), and Latina (OR = 0.22, 95% CI: 0.09-0.53) lesbian women also had significantly lower adjusted odds of obtaining contraceptive counseling relative to White heterosexual women. Conclusions: Policies, programs, and practices that facilitate access to person-centered contraceptive care among marginalized sexual orientation identity and racial/ethnic subgroups of U.S. women are needed to promote reproductive health equity.

Association of rural location and long acting reversible contraceptive use among Oregon Medicaid recipients

OBJECTIVE

To evaluate whether the use of long-acting, reversible contraception (LARC) is equitably accessible to Medicaid recipients in rural and urban areas. We also determined whether women's health specialists' availability was associated with the type of LARC used.

STUDY DESIGN

We used claims data for 242,057 adult women who were continuously enrolled in Oregon Medicaid for at least one year and at risk of pregnancy from January 1, 2015, through December 31, 2017 to assess the association between LARC utilization and (1) rurality and (2) provider supply. Our primary analysis included 430,918 person-years. Regression models adjusted for patient age, whether the patient was newly eligible for Medicaid due to Medicaid expansion, and health status. We also examined differences in the caseload of implants and IUD by provider type (women's health specialist vs other).

RESULTS

Among all women, 11.6% had at least one claim indicating LARC use. There was no significant difference in overall LARC use by location (urban residence +0.66%, 95% CI [-0.12%, 1.43%]), although urban residents were slightly more likely to have an IUD (+0.72%, 95% CI [0.11%, 1.33%]). An increase of one women's health specialty provider per 10,000 women was associated with a 0.14 percentage point increase in the rate of IUD utilization (95% CI: 0.02, 0.26). Compared to other providers, women's health specialty providers supplied 62% of all IUDs and 43% of all implants.

CONCLUSION

Among Oregon's Medicaid enrollees, LARC is equitably used in rural areas; however, IUD use is slightly more frequent in urban areas.

An Educational Intervention to Raise Awareness of Contraceptive Options Among Young People

Background: Young people in the United States know little about contraceptive options available to them, although method use is sensitive to individual preferences, and method switching is common. For young people to gain reproductive autonomy, a first step is to be aware of different contraceptives, including hormonal and nonhormonal methods. We tested whether an educational intervention delivered on community college campuses was effective in increasing contraceptive awareness. Materials and Methods: We developed a low-cost educational intervention featuring youth-friendly visual tools and tested its impact on method awareness and knowledge among 1,051 students of all genders, aged 18-25 years, at five community colleges. We used generalized estimating equations to test changes in awareness of a range of methods, including male and female (internal) condoms, the pill, patch, vaginal ring, shot, intrauterine devices, implant, and emergency contraception. Results: Over 90% of participants were aware of male condoms and the pill at baseline, but fewer had heard of other options (ranging from 31% to 76% for different methods). Across all methods, awareness increased to a mean of 88% among female participants and 82% among male participants postintervention. Awareness of the full range of methods increased from 31% to 55% (adjusted odds ratio [aOR]: 4.4, 95% confidence interval [CI]: 3.1-6.2]) among female participants and 11% to 36% (aOR: 10.8, 95% CI: 5.3-21.8) among male participants postintervention. The intervention was similarly effective by sexual orientation, race/ethnicity, nativity, or insurance coverage. Conclusion: This educational intervention significantly improved all students' awareness of a range of contraceptives, supporting one important aspect of reproductive health for young people in community settings.

Concerns About the Cost of Contraception Among Young Women Attending Community College

INTRODUCTION

Contraceptive use is lower among students attending community college than 4-year college students, which may be due to financial barriers to accessing contraceptives. This study examined insurance coverage, access to free or low-cost birth control, and concerns about contraceptive costs among women in community college.

METHODS

We analyzed data from a study conducted at five community colleges in California and Oregon, which have expanded Medicaid coverage of family planning services for low-income individuals. Participants were students aged 18-25 years who self-identified as female, had vaginal sex, and were not pregnant or trying to become pregnant (N = 389). Multivariate analyses were conducted to examine concerns about the cost of contraception among these young women and how cost concerns varied by insurance coverage and access to free or low-cost birth control.

RESULTS

Nearly one-half of participants (49%) were concerned about the cost of contraception. In multivariate models, privately insured women had lower odds of being concerned about the cost of birth control than the uninsured (adjusted odds ratio, 0.42; 95% confidence interval, 0.22-0.83), yet women with public insurance had cost concerns similar to those of women without insurance. Women who reported they knew where to get free or low-cost birth control had lower odds of reporting cost concerns (adjusted odds ratio, 0.42; 95% confidence interval, 0.24-0.75), as did the few women enrolled in a state family planning program (adjusted odds ratio, 0.56; 95% confidence interval, 0.32-1.00).

CONCLUSIONS

Even in states with publicly funded services for young people, concerns about the affordability of contraception were common among women, particularly the uninsured or publicly insured. Addressing students' cost concerns is an important aspect of ensuring access to contraception during their pursuit of higher education.

Patient and pharmacist perspectives on pharmacist-prescribed contraception: A systematic review

OBJECTIVE

Increasingly, states authorize pharmacists to prescribe hormonal contraception to patients without a prescription from another healthcare provider. The purpose of this review is to investigate pharmacist and patient perspectives on pharmacist-prescribed contraception in the United States.

STUDY DESIGN

We searched Medline, Embase, PsycInfo, CINAHL, Scopus, and the Cochrane Library from inception through July 10, 2019. We included qualitative and mixed-methods studies, quantitative surveys, observational studies, and randomized trials in the United States. Risk of bias was assessed using tools for quantitative and qualitative studies.

RESULTS

Fifteen studies met inclusion criteria, including studies on pharmacists and student pharmacists (n = 9), patients (n = 5), and both (n = 1). Study samples ranged from local to national. Studies had moderate to high risk of bias, primarily due to low response rates and lack of validated instruments. Most pharmacists (57-96%) across four studies were interested in participating in pharmacist-prescribed contraception services. Among patients, 63-97% across three studies supported pharmacist-prescribed contraception, and 38-68% across four studies intended to participate in these services. At least half of pharmacists across four studies felt comfortable prescribing contraception, though pharmacists identified additional training needs. Pharmacists and patients identified several reasons for interest in pharmacist-prescribed contraception services, including increasing patient access, reducing unintended pregnancies, and offering professional development for pharmacists. They also identified barriers, including payment, time and resource constraints, liability, and patient health concerns.

CONCLUSIONS

Most pharmacists and patients across 15 studies were interested in expanded access to contraception through pharmacist-prescribed contraception. Findings on facilitators and barriers may inform implementation efforts.

IMPLICATIONS

Pharmacist-prescribed contraception is a strategy to expand patient access to contraception. Reducing barriers to implementation could improve participation among pharmacists and patients.

Prevalence of contraindications to progestin-only contraceptive pills in a multi-institution patient database

OBJECTIVE

We calculated the prevalence of contraindications to progestin-only pills (POPs) among reproductive age women to evaluate the safety of over the counter provision.

STUDY DESIGN

This descriptive study queried a multi-institution US database to identify women ages 10 to 45 presenting for preventive care, and a subset of this initial cohort also presenting for contraceptive services, to estimate the prevalence of contraindications to POPs using diagnosis and procedure codes.

RESULTS

Among 813,888 females seeking preventive care between 2009 and 2015, 4.36% had a condition associated with a potential risk or unacceptable risk for initiation of POPs, compared to 2.29% of the 71,216 women seeking both preventive care and contraceptive services. Current breast cancer, the only condition classified as an unacceptable risk for initiation, was listed as a diagnosis for 2.67% and 0.57% in each respective group.

CONCLUSION

The prevalence of contraindications to POPs among reproductive age women is low. This finding supports the relative safety of an over the counter progestin-only contraceptive pill.

IMPLICATIONS

This analysis provides support for the safety of over the counter access to progestin-only contraceptive pills.

Pharmacists' perspectives and experience prescribing hormonal contraception in rural and urban New Mexico

BACKGROUND

Pharmacist prescription of contraception is becoming increasingly common in the United States (US). Limited information exists on whether this is improving access to contraception in underserved areas, including rural America.

OBJECTIVE

We sought to determine whether there were differences by rural location in pharmacists' willingness to prescribe hormonal contraception and perceived barriers to doing so.

METHODS

We conducted a cross-sectional survey of pharmacists eligible to prescribe hormonal contraception in New Mexico in March and May 2020. The survey consisted of demographic data, pharmacists' experience prescribing hormonal contraception, and questions regarding perceived barriers to pharmacist-prescribed hormonal contraception. Descriptive statistics assessed differences in survey responses between rural and urban pharmacists. We used multivariable logistic regression to estimate the association between rural practice and prescribing hormonal contraception.

RESULTS

Our sampling frame consisted of 822 licensed pharmacists. We received 256 responses, for a response rate of 31.1%. We found that rural pharmacists were as likely as their urban counterparts to prescribe hormonal contraception (adjusted odds ratio 1.22 [95% CI 0.56-2.68], P = 0.50). Five main barriers included a need for additional training, reimbursement for services, liability concerns, corporate policies, and shortage of staff. No difference in barriers were identified by rural location or staff role.

CONCLUSION

Pharmacy access has the potential to improve access to contraception across New Mexico, including underserved rural areas.

Clinical Applications of Telemedicine in Gynecology and Women's Health

Telemedicine and telehealth (TM/TH) are the 2 terms used interchangeably focusing on the delivery of health care services at a long distance using telecommunication technology. TM/TH has several gynecologic applications, including the well-woman visits, preventive care, preconception counseling, family planning including contraception and medical abortion, infertility workup, teleradiology, cervical cancer screening and colposcopy, mental health, and telesurgery. The goals of TM/TH are not only improving quality of health care in patients and building a virtual community of physicians but also increasing convenience, efficacy, and decreasing medical cost. In gynecology, TM/TH plays an important role, especially in well-woman care.

Nonindicated pelvic examinations during contraceptive encounters: Prevalence and provider variations

OBJECTIVE

Despite evidence that mandatory pelvic examinations deter contraceptive use and are not clinically necessary, survey research suggests that clinicians regularly perform pelvic examinations prior to prescribing contraceptives. This study estimates prevalence of nonindicated pelvic exams during contraceptive encounters, and variation in prevalence by provider specialty.

STUDY DESIGN

Using a national sample of commercial claims data, we identified contraceptive encounters without concurrent indication for pelvic examination among females aged 15 to 49 from 2007 to 2017. We first calculated the nonindicated exam rate by provider specialty and patient age. Using data from 2017 and linear probability models with metropolitan statistical area fixed effects, we estimated the differences in adjusted rates of nonindicated pelvic examination by provider specialty. To assess trends by provider specialty, we used all years of data and interacted specialty with year.

RESULTS

Of 7.9 million identified contraceptive encounters, 81.8% had no identified indications for pelvic exam. Exams were billed at 17.7% of these visits (2007-2017), and this rate increased from 13.4% in 2007 to 20.7% in 2017. The largest increase occurred among encounters with an obstetrician-gynecologist. In 2017, obstetrician-gynecologists were 20.3 percentage points (95% CI: 19%-21%) more likely to perform a concurrent pelvic exam compared to family physicians.

CONCLUSIONS

Pelvic examinations during contraceptive visits increased from 2007 to 2017. Increases occurred across all provider specialties, but were largely driven by obstetrician-gynecologists, who oversaw over half of all contraceptive encounters and performed non-indicated pelvic exams at the highest rate.

IMPLICATIONS

This research provides real-world evidence that suggests pelvic exams are increasingly performed during contraceptive encounters and that patients regularly undergo a low-value, invasive examination while obtaining contraceptive care. Continuing education, reimbursement reform, and more evidence on the harms of non-indicated pelvic exams will be necessary to change clinical practice.

A Randomized Study Evaluating the Effect of Evidence-Based Information on Clinician Attitudes About Moving Oral Contraceptives Over the Counter

Objective: To assess whether evidence-based information on progestin-only pills (POPs) and over-the-counter (OTC) oral contraceptives (OCs) increases support among clinicians for bringing a POP or combined oral contraceptive (COC) OTC and to identify concerns clinicians may have about OTC access to OCs. Materials and Methods: In 2018 a survey of 778 clinicians assessed support for bringing a POP and COC OTC before and after receiving evidence-based information, which was pretested through in-depth interviews. Clinicians were randomized into two groups, stratified by clinician type. One group received information about OTC access to OCs generally, and the second group received OTC information plus information about POPs. Levels of support between arms were compared using robust Poisson models. Results: Before receiving information, 31% of clinicians supported moving a POP OTC. After receiving information, 39% of clinicians who only received OTC information supported moving a POP OTC compared to 61% who received OTC and POP information (relative risk = 1.53, 95% confidence interval: 1.34 to 1.75). Support for bringing a COC OTC increased marginally for those who received OTC and POP information, while support among those who received only OTC information increased by 12 percentage points (to 50%). Among clinicians opposed to moving a POP OTC after receiving information, top concerns included safety (26%), effectiveness (19%), potential for incorrect use (19%), and loss of preventive screenings (15%). Conclusion: Evidence-based information, particularly around POPs, has the potential to change clinician attitudes and address misconceptions about POPs and OTC access.

Opposition to Pharmacist Contraception Services: Evidence for Rebuttal

Pharmacist contraception services are growing across the United States. Several states have authorized pharmacists to prescribe contraception, and the interest in other states continues to grow. Opposition to these practices exists and centers on discussions related to safety, training, cost, and fragmentation of care. We review these arguments and provide evidence refuting these concerns. Pharmacist-prescribed contraception increases access to care, and patients express interest in utilizing this service at the pharmacy. Pharmacists follow evidence-based recommendations. Counseling on preventative services and referral to other providers is part of contraception care by pharmacists. Training programs have been developed to equip both pharmacy students and pharmacists with the knowledge, skills, and tools needed to successfully provide these services. This article can serve as a guide for pharmacists and advocates when discussing pharmacist-prescribed contraception with policymakers, patients, and other healthcare professionals.