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Cosgriff L, Plummer M, Concepcion G, Danvers AA. Outcomes for Women Denied Postpartum Tubal Ligation During the Initial COVID-19 Surge. WOMEN'S HEALTH REPORTS (NEW ROCHELLE, N.Y.) 2024; 5:352-357. [PMID: 38666225 PMCID: PMC11044855 DOI: 10.1089/whr.2023.0142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 01/13/2024] [Indexed: 04/28/2024]
Abstract
Objective To evaluate the utilization and outcomes of postpartum long-acting reversible contraception (PPLARC) following unmet postpartum bilateral tubal ligation (PPBTL) requests during a time in which elective surgeries were canceled due to the initial COVID-19 surge. Methods We conducted a mixed-methods study using an embedded design. Using a retrospective cohort design, we collected data from patients seeking PPBTL following vaginal delivery between March 15, 2020, and June 20, 2020; this reflects a time period during which elective surgery was canceled thus making PPBTL unavailable. We recorded demographic data, method of contraception at time of discharge and 18 months postpartum, and incidence of interval pregnancy at 18 months postpartum. Additionally, we conducted five semistructured interviews to gain deeper insights into patient experiences with PPLARC as a bridge method. Results Forty-five patients had unfilled PPBTL requests with follow-up data available for 35. The median age was 34 years. Ten (22%) accepted PPLARC as a bridge to interval bilateral tubal ligation (BTL). At the 18-month mark, only 1 out of 7 (14.3%) PPLARC users had undergone an interval BTL procedure, compared to 11 out of 28 (39.3%) nonusers. None of the PPLARC users experienced pregnancies, while 6 out of 28 (21.6%) nonusers became pregnant. Qualitative interviews underscored themes such as inadequate counseling preparation for unmet PPBTL requests and persistent barriers to BTL access. Conclusions Raising awareness of unmet PPBTL risks may drive greater adoption of PPLARC as a bridge method. While not a substitution for PPTBL, PPLARC provides a reliable form of interval contraception for patients seeking to delay pregnancy. It is essential to recognize that patient security with PPLARC's contraceptive efficacy may introduce delays in achieving the desired interval sterilization. Enhancing antenatal counseling on contraception options and providing transparency regarding barriers to sterilization could mitigate the challenges associated with unmet PPBTL requests.
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Affiliation(s)
- Lauren Cosgriff
- Department of Obstetrics, Gynecology and Women's Health, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA
| | - Melissa Plummer
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Gabrielle Concepcion
- Department of Obstetric and Gynecology, New York University School of Medicine, New York, New York, USA
| | - Antoinette A. Danvers
- Department of Obstetrics, Gynecology and Women's Health, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA
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Permanent Contraception: Ethical Issues and Considerations: ACOG Committee Statement No. 8. Obstet Gynecol 2024; 143:e31-e39. [PMID: 38237165 DOI: 10.1097/aog.0000000000005474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
Abstract
Permanent contraception is the most used method of contraception among women aged 15-49 years and is one of the most straightforward surgical procedures an obstetrician-gynecologist can perform. At the same time, this therapeutic option is enormously complex when considered from a historical, sociological, or ethical perspective. This Committee Statement reviews ethical issues related to permanent contraception using a reproductive justice framework. Ethical counseling and shared decision making for permanent contraception should adopt a nonjudgmental, patient-centered approach, using up-to-date information about permanent contraception procedures and alternatives. Obstetrician-gynecologists should strive to avoid bringing into the clinical encounter biases around gender, race, age, and class that affect thoughts on who should or should not become a parent. Obstetrician-gynecologists should also ensure that permanent contraception requests reflect each patient's wishes, come from a desire to permanently end childbearing, and come from a preference for permanent contraception over all reversible methods as well as permanent contraception for the male partner. When difficulties in meeting a postpartum permanent contraception request are anticipated and permanent contraception is desired by the patient, transfer of care for the remainder of pregnancy should be offered. ACOG recognizes the right of all patients to unimpeded access to permanent contraception as a way of ensuring health equity, but it is unclear how to craft policies that protect from coercion but also do not create barriers to autonomously desired care. Determining the ethical balance between access and safeguards will require a collaborative interdisciplinary approach that involves a variety of stakeholders with varying perspectives.
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Fang NZ, Advaney SP, Castaño PM, Davis A, Westhoff CL. Female permanent contraception trends and updates. Am J Obstet Gynecol 2022; 226:773-780. [PMID: 34973178 DOI: 10.1016/j.ajog.2021.12.261] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 12/02/2021] [Accepted: 12/23/2021] [Indexed: 11/23/2022]
Abstract
Permanent contraception remains one of the most popular methods of contraception worldwide. This article has reviewed recent literature related to demographic characteristics of users, prevalence of use and trends over time, surgical techniques, and barriers to obtain the procedure. We have emphasized the patient's perspective as a key element of choosing permanent contraception. This review has incorporated sections on salpingectomy, hysteroscopy, unmet need, impact of policies at religiously affiliated institutions, and reproductive coercion.
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Affiliation(s)
- Nancy Z Fang
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY; Department of Obstetrics and Gynecology, University of Colorado Anschutz Medical Center, Aurora, CO.
| | - Simone P Advaney
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY
| | - Paula M Castaño
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY
| | - Anne Davis
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY
| | - Carolyn L Westhoff
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY; Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY
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Chiruvella M, Schaffir J, Benedict JA, Tedesco C, Loftus T, Henderson A, Yudovich M, Hade EM, Lynch CD. Is provision of contraception at discharge following delivery associated with postpartum visit attendance? Contraception 2020; 103:103-106. [PMID: 33098849 DOI: 10.1016/j.contraception.2020.10.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 10/14/2020] [Accepted: 10/14/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVES We examined whether provision of contraception at discharge following delivery was associated with lower rates of postpartum visit (PPV) attendance. METHODS We conducted a retrospective cohort study of women who received pregnancy care at a Midwestern medical center in 2013. Attendance at the postpartum visit was compared for women with sterilization, contraception initiated prior to discharge (depot medroxyprogesterone acetate or etonogestrel implant), hormonal contraception prescription, or no contraception provided at postpartum discharge. Poisson regression models with robust standard errors were used to estimate the relative risk of postpartum visit attendance controlling for age, race, and parity, insurance status, and histories of both depression and drug abuse. RESULTS Of the 1015 women who met inclusion criteria, 55% had been prescribed contraception, had initiated contraception prior to discharge, or were sterilized at the time of discharge following delivery. After adjustment for confounders, there was no association between receiving contraception and PPV attendance (relative risk for prescribed contraception = 1.09 [95% CI 0.85, 1.39], for contraception initiated prior to discharge = 0.83 [95% CI 0.67, 1.03], for sterilization = 0.86 [95% CI 0.63, 1.17] compared to no contraception). CONCLUSIONS We found no evidence that prescribing or administering contraception post-delivery was associated with lower rates of return for postpartum follow up. IMPLICATIONS This single site study suggests that providing effective contraception at discharge following delivery does not appear to impact PPV attendance.
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Affiliation(s)
- M Chiruvella
- Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, 395 12th Avenue, 5th Floor, Columbus, OH 43210, USA
| | - J Schaffir
- Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, 395 12th Avenue, 5th Floor, Columbus, OH 43210, USA.
| | - J A Benedict
- Center for Biostatistics, Department of Biomedical Informatics, The Ohio State University College of Medicine, 1800 Cannon Dr, 250 Lincoln Tower, Columbus, OH 43210, USA
| | - C Tedesco
- Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, 395 12th Avenue, 5th Floor, Columbus, OH 43210, USA
| | - T Loftus
- Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, 395 12th Avenue, 5th Floor, Columbus, OH 43210, USA
| | - A Henderson
- Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, 395 12th Avenue, 5th Floor, Columbus, OH 43210, USA
| | - M Yudovich
- Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, 395 12th Avenue, 5th Floor, Columbus, OH 43210, USA
| | - E M Hade
- Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, 395 12th Avenue, 5th Floor, Columbus, OH 43210, USA; Center for Biostatistics, Department of Biomedical Informatics, The Ohio State University College of Medicine, 1800 Cannon Dr, 250 Lincoln Tower, Columbus, OH 43210, USA
| | - C D Lynch
- Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, 395 12th Avenue, 5th Floor, Columbus, OH 43210, USA; Division of Epidemiology, The Ohio State University College of Public Health, Cunz Hall, 1841 Neil Ave, Columbus, OH 43210, USA
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Eisenach NA, Uvodich ME, Wolff SF, French VA. Initiation of Postpartum Contraception by 90 Days at a Midwest Academic Center. Kans J Med 2020; 13:202-208. [PMID: 32843924 PMCID: PMC7440850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 06/09/2020] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Contraception is a critical component of addressing the health needs of women in the postpartum period. We assessed contraception initiation by 90 days postpartum at a large, academic medical center in the Midwest. METHODS In this retrospective cohort study, 299 charts were randomly sampled and 231 were analyzed from deliveries between May 1 to July 5, 2018. Contraceptive method, maternal demographics, and obstetric characteristics at hospital discharge were collected, as well as contraceptive method at the postpartum follow-up appointment. Methods and strata of contraception were categorized as follows: 1) highly effective methods (HEM) defined as sterilization, intrauterine device, or implant, 2) moderately effective methods (MEM) defined as injectable contraception, progestin-only pills, and combined estrogen/progestin pills, patches, and rings, and 3) less effective methods (LEM) defined as condoms, natural family planning, and lactational amenorrhea. Women lost to follow-up who had initiated a HEM or injectable contraception were coded as still using the method at 90 days. We used logistic regression to identity factors associated with HEM use. RESULTS Of the 231 included patients, 118 (51%) received contraception before hospital discharge and 166 (83%) by 90 days postpartum. Postpartum visits were attended by 74% (171/231) of patients. Before hospital discharge, 28% (65/231) obtained a HEM and 41% (82/200) were using a HEM by 90 days postpartum. Patients obtaining HEM or injectable contraception before hospital discharge attended a follow-up visit less often than those who did not receive HEM before discharge (RR = 0.68, 95% CI: 0.54 - 0.86, p ≤ 0.01). CONCLUSION When readily available, many women will initiate contraception in the postpartum period. Health systems should work to ensure comprehensive access to contraception for women in the postpartum period.
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