1
|
Dahl CM, Turok D, Heuser CC, Sanders J, Elliott S, Pangasa M. Strategies for obstetricians and gynecologists to advance reproductive autonomy in a post-Roe landscape. Am J Obstet Gynecol 2024; 230:226-234. [PMID: 37536485 DOI: 10.1016/j.ajog.2023.07.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 07/18/2023] [Accepted: 07/26/2023] [Indexed: 08/05/2023]
Abstract
The monumental reversal of Roe vs Wade dramatically impacted the landscape of reproductive healthcare access in the United States. The decision most significantly affects communities that historically have been and continue to be marginalized by systemic racism, classism, and ableism within the medical system. To minimize the harm of restrictive policies that have proliferated since the Supreme Court overturned Roe, it is incumbent on obstetrician-gynecologists to modify practice patterns to meet the pressing reproductive health needs of their patients and communities. Change will require cross-discipline advocacy focused on advancing equity and supporting the framework of reproductive justice. Now, more than ever, obstetrician-gynecologists have a critical responsibility to implement new approaches to service delivery and education that will expand access to evidence-based, respectful, and person-centered family planning and early pregnancy care regardless of their practice location or subspecialty.
Collapse
Affiliation(s)
- Carly M Dahl
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City UT; Department of Obstetrics and Gynecology, Intermountain Health, Salt Lake City UT.
| | - David Turok
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City UT
| | - Cara C Heuser
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City UT; Department of Obstetrics and Gynecology, Intermountain Health, Salt Lake City UT
| | - Jessica Sanders
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City UT
| | - Sarah Elliott
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City UT
| | - Misha Pangasa
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City UT
| |
Collapse
|
2
|
Mock KO, Moyer A, Lobel M. Explaining sex discrepancies in sterilization rates in the United States: An evidence-informed commentary. PERSPECTIVES ON SEXUAL AND REPRODUCTIVE HEALTH 2023; 55:116-121. [PMID: 37594046 DOI: 10.1363/psrh.12243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/19/2023]
Abstract
CONTEXT With abortion no longer deemed a constitutional right in the United States (US), the importance of effective contraceptive methods cannot be overstated. Both male sterilization (vasectomy) and female sterilization (tubal ligation) have the lowest failure rates of available means of contraception. Despite the less invasive and reversible nature of vasectomy compared to tubal ligation procedures and even though some healthcare professionals dissuade certain women, especially those who are white and/or economically advantaged, from undergoing a sterilization procedure, female sterilization is approximately three times more prevalent than male sterilization in the US. PURPOSE We suggest that the discrepancy in sterilization rates is attributable to the burdens of pregnancy and birth experienced by women, beliefs that pregnancy prevention is a woman's responsibility, a dearth of sex education that results in lack of knowledge and poor understanding of contraception, perceptions of masculinity in which contraception is viewed as feminizing, and the increase in long-term singlehood that shapes the desire of individuals to avoid unwanted pregnancy that may result in single parenting. IMPLICATIONS Recent reports suggest that court rulings restricting abortion access and looming threats to contraceptive legality and accessibility may be prompting a national increase in male sterilization.
Collapse
Affiliation(s)
- K Olivia Mock
- Department of Psychology, Stony Brook University, Stony Brook, New York, USA
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Anne Moyer
- Department of Psychology, Stony Brook University, Stony Brook, New York, USA
| | - Marci Lobel
- Department of Psychology, Stony Brook University, Stony Brook, New York, USA
- Department of Obstetrics, Gynecology and Reproductive Medicine, Renaissance School of Medicine, Stony Brook University, Stony Brook, New York, USA
| |
Collapse
|
3
|
Arora KS, Chua A, Miller E, Boozer M, Serna T, Bullington BW, White K, Gunzler DD, Bailit JL, Berg K. Medicaid and Fulfillment of Postpartum Permanent Contraception Requests. Obstet Gynecol 2023; 141:918-925. [PMID: 37103533 PMCID: PMC10154035 DOI: 10.1097/aog.0000000000005130] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Accepted: 01/12/2023] [Indexed: 04/28/2023]
Abstract
OBJECTIVE To evaluate the association between Medicaid insurance and fulfillment of postpartum permanent contraception requests. METHODS We conducted a retrospective cohort study of 43,915 patients across four study sites in four states, of whom 3,013 (7.1%) had a documented contraceptive plan of permanent contraception at the time of postpartum discharge and either Medicaid insurance or private insurance. Our primary outcome was permanent contraception fulfillment before hospital discharge; we compared individuals with private insurance with individuals with Medicaid insurance. Secondary outcomes were permanent contraception fulfillment within 42 and 365 days of delivery, as well as the rate of subsequent pregnancy after nonfulfillment. Bivariable and multivariable logistic regression analyses were used. RESULTS Patients with Medicaid insurance (1,096/2,076, 52.8%), compared with those with private insurance (663/937, 70.8%), were less likely to receive desired permanent contraception before hospital discharge (P≤.001). After adjustment for age, parity, weeks of gestation, mode of delivery, adequacy of prenatal care, race, ethnicity, marital status, and body mass index, private insurance status was associated with higher odds of fulfillment at discharge (adjusted odds ratio [aOR] 1.48, 95% CI 1.17-1.87) and 42 days (aOR 1.43, 95% CI 1.13-1.80) and 365 days (aOR 1.36, 95% CI 1.08-1.71) postpartum. Of the 980 patients with Medicaid insurance who did not receive postpartum permanent contraception, 42.2% had valid Medicaid sterilization consent forms at the time of delivery. CONCLUSION Differences in fulfillment rates of postpartum permanent contraception are observable between patients with Medicaid insurance and patients with private insurance after adjustment for clinical and demographic factors. The disparities associated with the federally mandated Medicaid sterilization consent form and waiting period necessitate policy reassessment to promote reproductive autonomy and to ensure equity.
Collapse
Affiliation(s)
- Kavita Shah Arora
- Department of Obstetrics and Gynecology, the Department of Epidemiology, Gillings School of Global Public Health, and the Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; the Department of Obstetrics and Gynecology and the Center for Health Care Research and Policy, Population Health Research Institute, MetroHealth Medical System, Cleveland, Ohio; the Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Providence, Rhode Island; the Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama; the Department of Obstetrics and Gynecology, University of California, San Francisco, San Francisco, California; and the Department of Sociology, Steve Hicks School of Social Work, University of Texas at Austin, Austin, Texas
| | | | | | | | | | | | | | | | | | | |
Collapse
|
4
|
Ford A, Ascha M, Wilkinson B, Verbus E, Montague M, Morris J, Arora KS. Nonfulfillment of desired postpartum permanent contraception and resultant maternal and pregnancy health outcomes. AJOG GLOBAL REPORTS 2022; 3:100151. [PMID: 36655168 PMCID: PMC9841276 DOI: 10.1016/j.xagr.2022.100151] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Up to half of the patients requesting postpartum permanent contraception do not undergo the desired procedure. Although nonfulfillment of desired postpartum permanent contraception is associated with increased risk of pregnancy within 12 months of delivery, its long-term reproductive and maternal health outcomes are less clear. OBJECTIVE This study aimed to determine the association of fulfillment of postpartum permanent contraception with number and timing of subsequent pregnancies and maternal health outcomes. STUDY DESIGN This was a retrospective single-center cohort chart review study of health outcomes in the 4 years following delivery (2016-2018) for 1331 patients with a documented contraceptive plan of female permanent contraception at time of postpartum discharge from 2012 to 2014. Rates of permanent contraception fulfillment within 90 days of delivery and clinical and demographic characteristics associated with permanent contraception were calculated. We determined number of and time to subsequent pregnancies, and diagnoses of medical comorbidities (hypertension, diabetes mellitus, depression, anxiety, asthma, anemia), sexually transmitted infection, and pregnancy comorbidities (preterm birth, gestational diabetes mellitus, gestational hypertension, preeclampsia, postpartum hemorrhage, low birthweight, intrauterine fetal demise) in the 4 years following delivery. RESULTS Of the 1331 patients desiring permanent contraception postpartum, 588 (44.1%) had their requests fulfilled within 90 days of delivery and 743 (55.8%) did not. Patients who achieved permanent contraception fulfillment tended to have attended more outpatient prenatal visits, delivered via cesarean delivery, and were older, married, college-educated, and privately insured. Patients who received their desired postpartum permanent contraception were less likely to have subsequent intrauterine pregnancies (P<.001). In those who did not achieve permanent contraception, 22 (9.0%) subsequent pregnancies occurred within 6 months of previous deliveries, and 223 (91.0%) occurred after short interpregnancy intervals (within 18 months). Of 178 continued pregnancies, 26 (14.6%) were delivered preterm. There were no differences between the 2 groups in terms of ever attending an outpatient, preventive, or emergency room visit, or in most nonreproductive health outcomes investigated. CONCLUSION Nonfulfillment of desired postpartum permanent contraception is associated with subsequent maternal reproductive and nonreproductive health ramifications. Given the barriers to permanent contraception, alternative plans for contraception should be discussed proactively if permanent contraception is not provided.
Collapse
Affiliation(s)
- Aurora Ford
- Department of Bioethics, School of Medicine, Case Western Reserve University, Cleveland, OH
| | - Mustafa Ascha
- Cleveland Institute for Computational Biology, Case Western Reserve University, Cleveland, OH
| | - Barbara Wilkinson
- Department of Bioethics, School of Medicine, Case Western Reserve University, Cleveland, OH
| | - Emily Verbus
- Department of Bioethics, School of Medicine, Case Western Reserve University, Cleveland, OH
| | - Mary Montague
- Department of Bioethics, School of Medicine, Case Western Reserve University, Cleveland, OH
| | - Jane Morris
- Department of Bioethics, School of Medicine, Case Western Reserve University, Cleveland, OH
| | - Kavita Shah Arora
- Department of Bioethics, School of Medicine, Case Western Reserve University, Cleveland, OH,Department of Obstetrics and Gynecology, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH,Department of Obstetrics and Gynecology, The University of North Carolina at Chapel Hill, Chapel Hill, NC,Corresponding author: Kavita Shah Arora, MD, MBE, MS.
| |
Collapse
|
5
|
Short-notice cancellations of laparoscopic permanent contraception. Contraception 2022; 114:49-53. [DOI: 10.1016/j.contraception.2022.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Revised: 04/28/2022] [Accepted: 04/29/2022] [Indexed: 11/17/2022]
|
6
|
Henkel A, Beshar I, Goldthwaite LM. Postpartum permanent contraception: updates on policy and access. Curr Opin Obstet Gynecol 2021; 33:445-452. [PMID: 34534995 DOI: 10.1097/gco.0000000000000750] [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: 11/26/2022]
Abstract
PURPOSE OF REVIEW To describe barriers to provision of postpartum permanent contraception at patient, hospital, and insurance levels. RECENT FINDINGS Permanent contraception remains the most commonly used form of contraception in the United States with the majority of procedures performed during birth-hospitalization. Many people live in regions with a high Catholic hospital market share where individual contraceptive plans may be refused based on religious doctrine. Obesity should not preclude an individual from receiving a postpartum tubal ligation as recent studies find that operative time is clinically similar with no increased risk of complications in obese compared with nonobese people. The largest barrier to provision of permanent contraception remains the federally mandated consent for sterilization for those with Medicaid insurance. State variation in enforcement of the Medicaid policy additionally contributes to unequal access and physician reimbursement. Although significant barriers exist in policy that will take time to improve, hospital-based interventions, such as listing postpartum tubal ligation as an 'urgent' procedure or scheduling interval laparoscopic salpingectomy prior to birth-hospitalization discharge can make a significant impact in actualization of desired permanent contraception for patients. SUMMARY Unfulfilled requests for permanent contraception result in higher rates of unintended pregnancies, loss of self-efficacy, and higher costs. Hospital and federal policy should protect vulnerable populations while not preventing provision of desired contraception.
Collapse
Affiliation(s)
- Andrea Henkel
- Division of Family Planning Services & Research, Department of Obstetrics & Gynecology, Stanford University, Stanford, California, USA
| | | | | |
Collapse
|
7
|
Abstract
ABSTRACT Sterilization is one of the most effective and popular forms of contraception in the United States, relied upon by 18.6% of women aged 15-49 years using contraception. Nearly half of procedures are performed during the postpartum period, yet many women who desire postpartum sterilization do not actually undergo the procedure. Factors that may decrease the likelihood of a patient obtaining desired postpartum sterilization include patient-related factors, physician-related factors, lack of available operating rooms and anesthesia, federal consent requirements, and receiving care in some religiously affiliated hospitals. In all discussions and counseling regarding contraception, including postpartum sterilization, it is important to engage in shared decision making while supporting personal agency and patient autonomy. Equitable access to postpartum sterilization is an important strategy to ensure patient-centered care while supporting reproductive autonomy and justice when it comes to decisions regarding family formation. This revision includes updates on barriers to postpartum sterilization and guidance for contraceptive counseling and shared decision making.
Collapse
|
8
|
Welch EK, Lindberg M, Mauney D, McLeod F. Bring back the tubal: An intervention to provide postpartum tubal ligation in the underserved population. Health Care Women Int 2020; 45:113-128. [PMID: 32897839 DOI: 10.1080/07399332.2020.1805747] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 08/01/2020] [Indexed: 10/23/2022]
Abstract
We aimed to improve educational awareness of postpartum bilateral tubal ligation (PPBTL), which we defined as a 15% improvement between pre-/post-intervention questionnaire scores. We followed patients desiring and undergoing PPBTL and reason for unfulfilled procedures from 2017-2018. OB/GYN, Nursing, and Anesthesia participated in educational sessions with pre-/post-intervention questionnaires. Comparing the first and latter six months after study initiation, PPBTLs performed increased from 39% to 54%. Fifty-two staff participated in the interventions, with a 21% improvement in scores (OB/GYN p = 0.0117, Nursing p = 0.0001, Anesthesia p = 0.0002). We conclude multidisciplinary interventions improved educational awareness, an integral part to increasing PPBTL performance in the underserved.
Collapse
Affiliation(s)
- Eva K Welch
- Department of Obstetrics & Gynecology, Inova Fairfax Medical Campus, Falls Church, Virginia, USA
- Department of Obstetrics & Gynecology, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Mary Lindberg
- Department of Obstetrics & Gynecology, Inova Fairfax Medical Campus, Falls Church, Virginia, USA
| | - Donald Mauney
- Department of Anesthesiology, Geisinger Health System, Wilkes Barre, Pennsylvania, USA
| | - Francine McLeod
- Department of Obstetrics & Gynecology, Inova Fairfax Medical Campus, Falls Church, Virginia, USA
| |
Collapse
|
9
|
Bhide S, Ascha M, Wilkinson B, Verbus E, Montague M, Morris J, Arora KS. Variation in effectiveness of planned postpartum contraception at two time points from prenatal to postpartum care. Contraception 2020; 102:246-250. [PMID: 32540241 DOI: 10.1016/j.contraception.2020.06.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 06/01/2020] [Accepted: 06/03/2020] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To identify characteristics of women who have consistent plans in terms of contraceptive effectiveness from antepartum to postpartum care. STUDY DESIGN This is a secondary analysis of a retrospective chart review of women who delivered at a single tertiary care center from 2012 to 2014. Preferred postpartum contraceptive plan was abstracted at three time points (prenatal care, hospital discharge, and outpatient postpartum care) and categorized into three tiers of effectiveness. We then examined consistency between the first two time points for the effectiveness in postpartum contraceptive method planned. RESULTS Of the 8,394 women in the study cohort, 2,642 (31.5%) had a consistent postpartum contraceptive plan. Women who had a consistent plan were more likely to have higher parity (aOR 2.36, 95% CI 2.06-2.70 for parity 2+), choose highly effective methods of contraception (p < 0.001), achieve their contraception plan (adjusted odds ratio [aOR] 2.16, 95% confidence interval [95% CI] 1.85-2.52), but not more likely to have a subsequent pregnancy within 365 days of delivery (aOR 0.92, 95% CI 0.81-1.05). CONCLUSION Better understanding contraceptive decision-making as a journey and removing external barriers during that process is a necessary component of pregnancy care. IMPLICATIONS Counseling and documentation of contraceptive preferences throughout antepartum and postpartum care can help improve contraceptive outcomes.
Collapse
Affiliation(s)
- Sayuli Bhide
- School of Medicine, Case Western Reserve University, Cleveland, OH, United States
| | - Mustafa Ascha
- Cleveland Institute for Computational Biology, Case Western Reserve University, Cleveland, OH, United States
| | - Barbara Wilkinson
- School of Medicine, Case Western Reserve University, Cleveland, OH, United States
| | - Emily Verbus
- School of Medicine, Case Western Reserve University, Cleveland, OH, United States
| | - Mary Montague
- School of Medicine, Case Western Reserve University, Cleveland, OH, United States
| | - Jane Morris
- Department of Obstetrics and Gynecology, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, United States
| | - Kavita Shah Arora
- Department of Obstetrics and Gynecology, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, United States.
| |
Collapse
|