Reproductive health service preferences and perceptions of quality among low-income women: racial, ethnic and language group differences

Factors associated with unintended pregnancy and contraceptive practices in justice-involved adolescent girls in Australia

INTRODUCTION

Despite a decline in unintended teenage pregnancy in Australia, rates remain higher amongst justice-involved adolescent girls, who are more likely to be from disadvantaged socio-economic backgrounds, have histories of abuse, substance use and/or mental health issues. Furthermore, exposure to the criminal justice system may alter access to education and employment and opportunities, potentially resulting in distinct risk-factor profiles. We examine factors associated with unintended pregnancy, non-contraceptive use and Long-Acting Reversible Contraception (LARC) in a sample of sexually active, justice-involved adolescent girls from Western Australia and Queensland.

METHODS

Data from the Mental Health, Sexual Health and Reproductive Health of Young People in Contact with the Criminal Justice System (MeH-JOSH) Study was analysed on 118 sexually active adolescent girls. Participants were aged between 14 and 17 years, purposefully sampled based on justice-system involvement and completed an anonymous telephone survey. We constructed two multivariate models taking reproductive outcomes as the dependent variables.

RESULTS

Over one quarter (26%, 30/118) reported a past unintended pregnancy, 54 did not use any contraception at their last sexual encounter, and 17 reported LARC use. Following adjustments in the multivariate analysis, lifetime ecstasy use was associated with both unintended pregnancy (aOR 3.795, p = 0.022) and non-contraception use (aOR 4.562, p = 0.004). A history of physical abuse was also associated with both any contraception (aOR 3.024, p = 0.041) and LARC use (aOR 4.892, p = 0.050). Identifying as Aboriginal & Torres Strait Islander, education/employment status and geographic location appeared to have no association.

CONCLUSION

Our findings suggest that justice-involved adolescent girls have distinct risk factors associated with unplanned pregnancy and contraception use compared to the general population, but more research is required to understand the mechanisms and contexts underlying these risk factors. How exposure to physical violence may encourage contraception and LARC use, in particular, warrants further attention as does the association with ecstasy use.

Perspectives from the pandemic epicenter: Sexual and reproductive health of immigrant women in New York City

CONTEXT

The United States' response to COVID-19 created a policy, economic, and healthcare provision environment that had implications for the sexual and reproductive health (SRH) of racialized and minoritized communities. Perspectives from heterogenous immigrant communities in New York City, the pandemic epicenter in the United States (US), provides a glimpse into how restrictive social policy environments shape contraception, abortion, pregnancy preferences, and other aspects of SRH for marginalized immigrant communities.

METHODS

We conducted in-depth interviews in 2020 and 2021 with 44 cisgender immigrant women from different national origins and 19 direct service providers for immigrant communities in New York City to explore how immigrants were forced to adapt their SRH preferences and behaviors to the structural barriers of the COVID-19 pandemic. We coded and analyzed the interviews using a constant comparative approach.

RESULTS

Pandemic-related fears and structural barriers to healthcare access shaped shifts in contraceptive use and preferences among our participants. Immigrant women weighed their concerns for health and safety and the potential of facing discrimination as part of their contraceptive preferences. Immigrants also described shifts in their pregnancy preferences as rooted in concerns for their health and safety and economic constraints unique to immigrant communities.

CONCLUSION

Understanding how immigrant women's SRH shifted in response to the structural and policy constraints of the COVID-19 pandemic can reveal how historically marginalized communities will be impacted by an increasingly restrictive reproductive health and immigration policy landscape.

Judgment, shame, and coercion: the criminal legal system and reproductive autonomy

BACKGROUND

A growing body of research has called attention to limitations to reproductive autonomy in both women who are socially disadvantaged and in those who have had contact with the criminal legal (CL) system. However, it is unclear whether CL system contact influences contraceptive use patterns and how these processes unfold. We utilize a mixed-methods approach to investigate whether history of arrest is associated with receipt of contraceptive counseling, use of long-term contraception, sterilization, and subsequent desire for reversal of sterilization. We further consider how agents in and around the CL system may influence women's reproductive decisions and outcomes (856 survey respondents; 10 interviewees).

RESULTS

We observe that women who have been arrested more commonly report receipt of contraceptive counseling and sterilization. They are also significantly more likely to want their sterilization reversed. Our in-depth interviews suggest that women with CL contact experience considerable shame, and in some cases, coercion to limit fertility from various agents in and outside the criminal legal system including medical providers, Parole/Probation Officers (POs), guards, and family members.

CONCLUSIONS

Our findings suggest the need for ongoing attention to how exposure to this system may promote uneven use of certain forms of contraception and dissatisfaction, i.e., desire for reversal of sterilization, among these women. Findings further suggest that de-emphasizing the CL system as a means through which to address reproductive needs should be considered.

Provider perspectives on a point-of-care tool to facilitate patient-centered contraceptive care among Latina/x patients in Baltimore, MD

Objectives

To explore clinician perspectives on the development, utility, and feasibility of a provider-facing point-of-care tool to assist in provision of patient-centered contraceptive care for Latina/x patients in Baltimore, MD.

Methods

We conducted 25 semi-structured qualitative interviews with a sample of clinicians who provide contraceptive care to Latina/x patients. An interview guide was developed based on prior research related to patient-centered care and extant point-of-care tools. Transcripts were independently coded by two study team members and analyzed using a directed content analysis approach.

Results

Four themes emerged from the data: (1) clinician perception of a need for a tool to facilitate patient-centered contraceptive care, (2) concern for tool burden and burnout, (3) desire for tool ease of use, and (4) a need for cultural awareness during tool development to avoid bias and typecasting.

Conclusions

A provider-facing, point-of-care tool to facilitate patient-centered contraceptive counseling was acceptable among providers, provided the tool is easy to use and promotes cultural awareness.

Innovation

In the current era of more limited reproductive choice across the U.S., the need and support for non-coercive, patient-centered contraceptive care is timely. A provider-facing, point-of-care tool can facilitate the provision of patient-centered care among clinicians proving contraceptive counseling to Latina/s.

Digital HPV education to increase vaccine uptake among low income women

Objective

The objective of this formative study was to gather women's perspectives in the design and communication modalities of a health kiosk set within a Planned Parenthood setting to promote patient education about the Human papillomavirus (HPV) and to motivate uptake of the HPV vaccine.

Methods

Twenty-four women aged 18-35 participated in in-depth one-on-one interviews at a Planned Parenthood health center, which were analyzed in code-associated categories using NVivo11 Pro.

Results

Most women showed receptivity to using an on-site health kiosk, as well as QR codes linked to text messages, to receive HPV-related health information outside of the clinic setting and reminders. Participants provided suggestions for kiosk design and communication modalities.

Conclusions

Among low-income women we interviewed at Planned Parenthood, increasing HPV vaccination rates necessitates engaging digital health tools which incorporate both the preferences and needs of vulnerable populations.

Innovation

Designing a point-of-service health kiosk that 1) draws on user preferences early in the design phase, 2) integrates multiple communication technologies, and 3) disseminates culturally grounded HPV vaccination decisions narratives that are tailored to vaccination awareness level is a promising approach in reducing barriers to HPV vaccine education and vaccine uptake among low-income women at safety-net clinics.

"It Wasn't Very Public-Clinicy": Client Experiences at Faith-Based Pregnancy Centers

Faith-based pregnancy centers strive to offer "alternatives to abortion" that supporters claim aid women and critics assert manipulate pregnant people, stigmatize abortion, and potentially delay clients from obtaining medical care. However, scholars know little about the exchanges within appointments and how clients make sense of these experiences. Drawing on ethnographic observations of client appointments in two pregnancy centers in the West and 29 in-depth interviews with clients, this article uses an intersectional framework to analyze client experiences. Clients favorably compared centers to clinical health care providers, emphasizing the unexpectedly attentive emotional care they received. These evaluations stem from clients' reproductive histories, which are shaped by gender, racism, and economic inequalities that configure their access to and interactions within the health system. Emotional care serves to create and maintain pregnancy centers' impression of legitimacy among clients.

Prioritizing patient experience: Validation of the person-centered contraceptive counseling measure as a performance measure

OBJECTIVE

A performance measure assessing how often patients experience patient-centered contraceptive counseling can inform quality improvement in contraceptive care and enable efforts to enhance equity in the provision of this care. We sought to test the validity and reliability of the Person-Centered Contraceptive Counseling (PCCC) measure as a performance measure, in preparation for application for endorsement from the National Quality Forum.

STUDY DESIGN

We combined data from two research studies, a statewide quality improvement assessment, and a dedicated data collection effort at nine sites, all collected between 2009 and 2019 at 22 total sites in the United States, to evaluate the validity and reliability of the four-item PCCC measure aggregated at the provider and facility level. We scored the PCCC dichotomously as a "top-box" score of 20 versus less than 20. We assessed reliability using the Spearman-Brown coefficient, and validity by comparing scores on the PCCC to aggregated scores on single-item measures of patient satisfaction.

RESULTS

We included 22 facilities and 34 providers in the analyses. The average PCCC top-box score by provider and facility was 81% and 79%, respectively. We found adequate reliability with panel sizes of 20-50. PCCC scores were strongly associated with the single-item measures of satisfaction. There were notable disparities by race/ethnicity and language (Spanish vs English) in PCCC scores.

DISCUSSION

The PCCC is a valid and reliable performance measure for use at the provider and facility level. The development and use of the measures of patient experience, like the PCCC, is critical for prioritizing patient-centeredness in reproductive health care.

IMPLICATIONS

The PCCC measure can facilitate the identification of gaps and disparities in patient-centered contraceptive counseling and enable quality improvement to promote quality, equitable contraceptive care. Using this measure provides the opportunity to enhance patient experience of care and build trust between contraceptive providers and the communities they serve.

"She should support me, she's my doctor:" Patient perceptions of agency in contraceptive decision-making in the clinical encounter in Northern California

INTRODUCTION

Agency in contraceptive decision-making is an essential aspect of reproductive autonomy. We conducted qualitative research to investigate what agency means to patients seeking contraceptive care to inform the development of a validated measure of this construct.

METHODOLOGY

We held four focus group discussions and seven interviews with sexually-active individuals assigned female at birth, ages 16-29 years, recruited from reproductive health clinics in Northern California. We explored experiences in contraceptive decision-making during the clinic visit. We coded data in ATLAS.ti and by hand, compared codes across three coders, and used thematic analysis to identify salient themes.

RESULTS

The sample mean age was 21 years, with 17% of participants identifying as Asian, 23% as Black, 27% as Latinx, 17% as Multiracial/other, and 27% as white. Overall, participants reported active and engaged decision-making in their recent contraceptive visit but noted experiences that had undermined their agency in the past. They described how non-judgmental care allowed them to communicate openly, affirming their ability to make their own decisions. However, several mentioned how unexpected contraceptive side effects after the visit had reduced their sense of agency over their decision in retrospect. Several participants, including those who identified as Black, Latinx, and/or Asian, described prior experiences where pressure to use a contraceptive method had undermined their agency and where they had switched providers to regain agency over their contraceptive decisions.

DISCUSSION

Most participants were aware of their agency during contraceptive visits and how it varied in different experiences with providers and the healthcare system. Patient perspectives can help to inform measurement development and ultimately the delivery of care that supports contraceptive agency.

Acceptability of reproductive goals assessment in public mental health care

OBJECTIVE

To assess patient and provider perspectives on the acceptability of reproductive goals assessment in public mental health clinics and inform potential tailoring for these settings.

DATA SOURCES AND STUDY SETTING

Primary qualitative data from patients and providers at four clinics in an urban public mental health system serving individuals with chronic mental illness (collected November 2020-October 2021).

STUDY DESIGN

This was an exploratory qualitative study with patients (English-speaking women of reproductive age, primarily Black or Latina) and mental health providers (psychiatrists, psychotherapists, case managers, nurses). We examined the acceptability of reproductive goals assessment within mental health care and obtained feedback on two reproductive goals assessment conversation guides: PATH (Pregnancy Attitudes, Timing, and How Important is Pregnancy Prevention) and OKQ (One Key Question).

DATA COLLECTION

We conducted semi-structured telephone interviews with 22 patients and 36 providers. We used rapid qualitative analysis to summarize interview transcripts and identified themes using matrix analysis.

PRINCIPAL FINDINGS

Perceptions of reproductive goals assessment were generally positive. Providers said the conversation guides would "open the door" to important discussions, support a better understanding of patients' goals, and facilitate medication counseling and planning. A minority of patients expressed discomfort or ambivalence; several suggested providers ask permission or allow patients to raise the topic. Additional themes included the need for framing to provide context for these personal questions, the need to build rapport before asking them, and the challenge of balancing competing priorities. Many participants found both PATH and OKQ prompts acceptable; some preferred the "conversational" and "open-ended" PATH phrasing.

CONCLUSIONS

Participants perceived reproductive goals assessment as a promising practice in mental health care with unique functions in this setting. Areas of discomfort highlight the sensitivity of these topics for some women with chronic mental illness and suggest opportunities to tailor language, framing, and provider training to support effective and appropriate implementation.

Frequency of Contraception Documentation in Women With Systemic Lupus Erythematosus and Rheumatoid Arthritis Within the Rheumatology Informatics System for Effectiveness Registry

OBJECTIVE

We sought to understand the frequency of contraception documentation for women with systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA) in a large US electronic health record (EHR)-based registry and to identify disparities by teratogen prescription and patient race and ethnicity.

METHODS

Contraception documentation from structured data fields within the Rheumatology Informatics System for Effectiveness (RISE) registry was collected for women of childbearing age (18-45 years) in 2018 who had at least 2 visits with International Classification of Diseases, Ninth Revision or Tenth Revision, diagnosis codes for SLE or RA (at any time). Univariate and multivariate analyses compared the frequency of contraception documentation based on patient characteristics including diagnosis, age, race, and teratogenicity of prescribed antirheumatic medications.

RESULTS

In 2018, there were 9,826 women of childbearing age with SLE and 19,009 with RA, of whom 9.1% had any contraception documented. Rates of contraceptive documentation were significantly lower for women with SLE (adjusted odds ratio [OR] 0.84 [95% confidence interval (95% CI) 0.76-0.92]). Women of Hispanic ethnicity and Black and Asian race were all less likely than White women to have contraception documentation. Teratogen prescription was associated with higher rates of contraception documentation for women with RA but not SLE (RA adjusted OR 1.31 [95% CI 1.16-1.47]; SLE adjusted OR 1.08 [95% CI 0.91-1.28]).

CONCLUSION

There are large gaps in contraception documentation within the RISE registry that are particularly stark among women of color. Although these data likely underestimate contraception use, they highlight that most rheumatologists do not have a systematic approach to collecting and recording this information in the EHR.

Provider perspectives on patient-centered contraceptive counseling for Latinas in Baltimore, MD

OBJECTIVES

To explore: 1) provider narratives of their contraceptive counseling practices with Latina patients within the context of patient-centered care (PCC); and 2) provider perceptions about the barriers to the provision of patient-centered contraceptive counseling in general and more specifically, with Latina patients in Baltimore, MD.

STUDY DESIGN

We conducted 25 semistructured qualitative interviews with physicians  and nurse practitioners from four specialties who provide contraceptive care to Latinas in Baltimore, MD. We analyzed data using directed content analysis. We discuss findings with attention to major constructs of PCC, applying a reproductive justice framework.

RESULTS

Providers described a contraceptive counseling approach focused on pregnancy prevention as the primary goal. Most respondents used a tiered-effectiveness approach, even while noting the importance of PCC. Providers noted health system barriers to PCC, including time constraints and insurance status. Provider-reported patient-attributed barriers included low patient education/health literacy, culturally-attributed misconceptions about contraception, and language discordance.

CONCLUSION

Providers described knowledge of and intention to practice PCC but had limited integration of it in their own counseling with Latinas. Responses suggest tension between an expressed desire to provide PCC and paternalistic counseling paradigms that prioritize pregnancy prevention over patient preferences. Inequitable health system barriers also interfere with true implementation of contraceptive PCC.

IMPLICATIONS

Translating contraceptive PCC into practice, especially for marginalized communities, is paramount. Training should teach clinicians to recognize systems of structural inequity and discrimination that have informed approaches to counseling but are not reflective of PCC. Institutional policies must address health system barriers that also hamper PCC.

Long-acting reversible contraception: Targeting those judged to be unfit for parenthood in the United States and the United Kingdom

There is a long history of regarding marginalised groups as unfit to parent and of eugenic policies targeting those with 'undesirable' bodily conditions or behaviours. This is part of a broader pattern of stratified reproduction - structural conditions that enable or discourage certain groups from reproducing - that often brings about and exacerbates injustices. This paper critically assesses the US and UK social and medical literature on applying pressure to marginalised groups, or those who have behaved 'irresponsibly', to use long-acting reversible contraception (LARC). Targeting young people for LARC fails to recognise that social inequality is the context for teenage pregnancy, not the result of it. Provider pressure on women of colour to use LARC is linked to institutional racism, whilst policy for those with physical and intellectual disabilities is shaped by disability discrimination. Other groups to be targeted include so-called 'welfare mothers', substance users, those who have had children put into care and offenders. Particularly controversial are cases in which LARC has been ordered by courts. LARC policy incorporating these kind of discriminatory practices needs to stop; future policy should focus on person-centred care that bolsters reproductive justice.

Patterns in Contraceptive Use Among Women of Mexican Origin in the United States and in Mexico

Nulliparous women of Mexican origin in the United States and Mexico are less likely to use effective contraception than parous women, suggesting limited contraceptive access before childbearing.

To examine current contraceptive use by parity among four ethnicity and nativity groups: non-Latina White women in the United States, Mexican-American women in the United States, foreign-born women of Mexican origin in the United States, and Mexican women in Mexico.

Evaluating the MyPath web-based reproductive decision support tool in VA primary care: Protocol for a pragmatic cluster randomized trial

BACKGROUND

Counseling to identify and support individuals' desires for family formation is a key component of preventive health care that is often absent in primary care visits. This study evaluates a novel, web-based, person-centered intervention to increase the frequency and quality of communication about reproductive goals and healthcare needs in Veterans Health Administration (VA) primary care.

METHODS

We describe a hybrid type 1 effectiveness-implementation cluster randomized controlled trial in seven VA healthcare systems testing a web-based reproductive health decision support tool (MyPath). VA primary care providers are enrolled and randomized to intervention or usual care arms. Veterans scheduled to see intervention-arm providers receive a text message inviting them to use MyPath ahead of their appointment; Veterans scheduled to see control-arm providers receive usual care. Target enrollment is 36 providers and 456 Veterans. Outcomes are assessed by Veteran self-report after the visit and at 3- and 6-months follow-up. The primary outcome is occurrence of reproductive health discussions involving shared decision making; secondary outcomes include measures of communication, knowledge, decision conflict, contraceptive utilization, and receipt of services related to prepregnancy health. Data on implementation barriers, facilitators and cost are collected.

RESULTS

The trial is ongoing with no results to report. We have enrolled 36 primary care providers across 7 VA healthcare systems and recruitment of Veterans is ongoing.

CONCLUSIONS

Results will inform efforts to increase the quality and person-centeredness of reproductive healthcare delivery in primary care and to operationalize and scale up use of digital decision support tools in clinical settings.

TRIAL REGISTRATION

http://ClinicalTrials.gov Identifier: NCT04584294 Trial Status: Recruiting.

Perceived Contraceptive Counseling Quality Among Veterans Using VA Primary Care: Data from the ECUUN Study

BACKGROUND

High-quality contraceptive counseling is critical to support Veterans' reproductive autonomy and promote healthy outcomes.

OBJECTIVE

To describe perceived quality of contraceptive counseling in Veterans Health Administration (VA) primary care and assess factors associated with perceived high- and low-quality contraceptive counseling.

DESIGN

Cross-sectional study using data from the Examining Contraceptive Use and Unmet Need in women Veterans (ECUUN) national telephone survey.

PARTICIPANTS

Veterans aged 18-44 who received contraceptive services from a VA primary care clinic in the past year (N=506).

MAIN MEASURES

Perceived quality of contraceptive counseling was captured by assessing Veterans' agreement with 6 statements regarding provider counseling adapted from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey. High-quality counseling was defined as a top score of strongly agreeing on all 6 items; low-quality counseling was defined as not agreeing (neutral, disagreeing, or strongly disagreeing) with >3 items. We constructed two multivariable models to assess associations between patient-, provider-, and system-level factors and perceived high-quality (Model 1) and perceived low-quality counseling (Model 2).

KEY RESULTS

Most participants strongly agreed that their providers listened carefully (74%), explained things clearly (77%), and spent enough time discussing things (71%). Lower proportions strongly agreed that their provider discussed more than one option (54%), discussed pros/cons of various methods (44%), or asked which choice they thought was best for them (62%). In Model 1, Veterans who received care in a Women's Health Clinic (WHC) had twice the odds of perceiving high-quality counseling (aOR=1.99; 95%CI=1.24-3.22). In Model 2, Veterans who received care in a WHC (aOR=0.49; 95%CI=0.25-0.97) or from clinicians who provide cervical cancer screening (aOR=0.49; 95%CI=0.26-0.95) had half the odds of perceiving low-quality counseling.

CONCLUSIONS

Opportunities exist to improve the quality of contraceptive counseling within VA primary care settings, including more consistent efforts to seek patients' perspectives with respect to contraceptive decisions.

Association of Title X clinic status with receipt of person-centered contraceptive counseling: a population-based study

OBJECTIVE

To describe receipt of person-centered contraceptive counseling among reproductive-aged women in the United States who sought contraceptive care at Title X clinics, non-Title X public clinics, and private clinics.

STUDY DESIGN

We conducted a secondary analysis of the 2017-2019 wave of the National Survey of Family Growth (NSFG). The sample included female respondents ages 15-49 who received contraceptive services in the past year and completed the Person-Centered Contraceptive Counseling (PCCC) measure, a quality metric evaluating interpersonal quality of the care received. We used multivariable logistic regression to estimate the predicted probability of receiving person-centered contraceptive counseling by source of care, adjusted for individual-level characteristics.

RESULTS

Of 2,225 (weighted N=26,599,620) eligible respondents, 6.9% received care at a Title X clinic, 8.2% at a non-Title X public clinic, and 84.9% at a private clinic. The adjusted predicted probability of receiving person-centered contraceptive counseling among respondents attending private clinics was 50.6% (95% CI 46.3-54.8%) compared with 51.3% (95% CI 40.4-62.3%) at Title X clinics and 52.4% (95% CI 44.0-60.7%) at other public clinics. Respondents with incomes ≥300% above the federal poverty level (FPL) had higher odds of reporting receipt of person-centered counseling compared to those with incomes below 100% of the FPL (aOR = 2.12; 95% CI 1.47-3.06). Non-Latina Black respondents had lower odds of receiving person-centered contraceptive counseling (aOR = 0.69; 95% CI 0.51-0.94), compared to non-Latina white respondents.

CONCLUSION

Title X clinics perform as well as the private sector in delivering person-centered contraceptive counseling.

IMPLICATIONS

Title X clinics provide quality person-centered contraceptive counseling on par with the private sector, despite serving populations that are often less likely to report high quality care. Broad implementation of the PCCC measure will permit tracking person-centered contraceptive care across diverse practice settings and populations.

A Framework for Femtech: Guiding Principles for Developing Digital Reproductive Health Tools in the United States

The United States has abysmal reproductive health indices that, in part, reflect stark inequities experienced by people of color and those with preexisting medical conditions. The growth of "femtech," or technology-based solutions to women's health issues, in the public and private sectors is promising, yet these solutions are often geared toward health-literate, socioeconomically privileged, and/or relatively healthy white cis-women. In this viewpoint, we propose a set of guiding principles for building technologies that proactively identify and address these critical gaps in health care for people from socially and economically marginalized populations that are capable of pregnancy, as well as people with serious chronic medical conditions. These guiding principles require that such technologies: (1) include community stakeholders in the design, development, and deployment of the technology; (2) are grounded in person-centered frameworks; and (3) address health disparities as a strategy to advance health equity and improve health outcomes.

Protocol versus practice: Deviations from guidelines in low-risk twin deliveries in the United States

BACKGROUND

Medical guidelines recommend vaginal delivery for low-risk twin pregnancies because cesareans increase the probability of maternal morbidity and mortality. Yet, vaginal delivery rates for twins are considerably lower than for comparable singletons. One explanation for this disparity argues that greater risk associated with twins warrants increased surgical intervention. An alternative explanation is that twin deliveries are more likely to deviate from protocols that advise vaginal birth.

METHODS

Using the 2017 Natality Detail File (N = 3,197,401), we measured alignment of vaginal birth and trial of labor (TOL) with the American College of Obstetricians and Gynecologists' guidelines for twin and singleton no-indicated-risk births. We calculated predicted probabilities for the population and by maternal race/ethnicity to assess whether low rates of vaginal births among twins are explained by associated risk factors, or by deviations from recommended delivery methods.

RESULTS

Overall, 31.2% of twins were born vaginally compared with 79.4% of singletons. Controlling for indicated risks, the predicted probability of vaginal birth for twins was 0.49 and 0.85 for singletons. The predicted probability of TOL for twins was 0.18 and 0.47 for singletons. Maternal race/ethnicity was only weakly associated with mode of delivery. These findings indicate that no-indicated-risk twin pregnancies, across maternal racial/ethnic categories, have lower probabilities of vaginal birth and TOL than would be expected with widespread adherence to current guidelines.

CONCLUSIONS

Given the life-threatening consequences that may result from unnecessary surgical procedures, our findings highlight the need for further research to illuminate medical and nonmedical mechanisms driving nonadherence to clinical guidelines for twin births.

Women's experiences with person-centered family planning care: Differences by sociodemographic characteristics

Objective

Person-centered contraceptive care is associated with positive reproductive health outcomes. Our objective was to analyze patients’ ratings on the newly developed Person-Centered Contraceptive Counseling scale (PCCC) to provide distributions for a nationally representative population and to assess differences by sociodemographic characteristics.

Study design

Using data from 2017 to 2019 National Survey of Family Growth (NSFG), we analyzed ratings across the four PCCC items among 2242 women who received contraceptive counseling in the past year. Items measured patients’ reports of how providers respected them, let them describe their contraceptive preferences, took their preferences seriously, and adequately informed them about their options. We studied each PCCC item individually as well as the combined scale, distinguishing between ratings of “excellent” versus lower ratings. Bivariate and multivariate logistic regression models assessed how patients’ characteristics (age, race/ethnicity and English proficiency, sexual orientation, income, and parity) and provider type were associated with the likelihood of experiencing person-centered care.

Results

The majority of women (59%–69%) reported that their family planning provider was “excellent” across the four PCCC items and just over half (51%) reported “excellent” on all items. In multivariate analyses, having a lower income, Black race, non-heterosexual identity, and Hispanic ethnicity combined with low English proficiency were associated with lower PCCC ratings.

Conclusions

In a nationally representative sample, the PCCC captured variation in women's experiences with person-centered family planning care by sociodemographic characteristics. Findings highlight the need for contraceptive counseling that centers on clients’ preferences and experiences, particularly for patients who belong to groups experiencing health inequities.

Implications

Person-centered care is a key component of high-quality family planning services. This analysis highlights sociodemographic disparities in person-centered care by analyzing PCCC ratings. Findings show the value of this new health care performance measure and affirm the need for family planning care that centers individuals' preferences and lived experiences.

Contraceptive Decision-Making and the Importance of Side Effect Information Among a Sample of Latinas

Context: U.S. Latinas have lower rates of contraceptive use and report more negative counseling experiences compared to non-Latina white women. Patient-centered approaches to contraceptive counseling are desired among Latinas and are also associated with patient satisfaction; yet, clinicians may not always use counseling methods that best support decision-making among marginalized groups.

Objective: To examine Latinas' expectations of physician communication about contraceptive side effects, reported importance of personal knowledge about side effects, and the association of these with contraceptive use and use consistency.

Materials and Methods: One hundred three self-identified Latinas aged 15–29 years at two urban federally qualified health centers completed a survey measuring factors associated with contraceptive use and consistency. Bivariate analysis was used to assess demographic and contraceptive information preferences. Associations between categorical variables were assessed using two-sided Fisher's exact tests. Continuous variables were compared using two-sided t-test.

Results: The majority of respondents (85%) expected physicians to tell them about birth control side effects and reported that this information is important to use contraception, regardless of current contraceptive use. Among inconsistent and nonusers, importance of knowledge of side effects depended on expectations of information-sharing from physicians (p < 0.05).

Conclusions: Expectations regarding side effect information-sharing by physicians and patient knowledge of side effects are important for the contraceptive decision-making process of this Latina group, regardless of contraceptive use. Clinicians engaging in contraceptive counseling should focus on providing clear and accurate information about side effects of discussed methods to facilitate informed decision-making and equitable, patient-centered contraceptive care for this vulnerable population.

Contraceptive counselling experiences in Spain in the process of creating a web-based contraceptive decision support tool: a qualitative study

Background

The choice of contraceptive method is a complex decision, and professionals should offer counselling based on the preferences, values and personal situation of the user(s). Some users are unsatisfied with the counselling received, which may, among other consequences, adversely affect method use adherence. In view of this situation, we propose exploring the experiences and needs of users and professionals for contraceptive counselling, in the context of creating a web-based contraceptive decision support tool.

Methods/design

Qualitative research was conducted through focus group discussions (64 users split into eight groups, and 19 professionals in two groups, in Tarragona, Spain) to explore the subjects’ experiences and needs. The data were categorized and the categories were defined and classified based on the three-step protocol or framework for Quality on Contraceptive Counseling (QCC), created by experts, which reviews the quality of interactions between user and professional during the counselling process.

Results

In counselling, users demand more information about the different methods, in an environment of erroneous knowledge and misinformation, which lead to false beliefs and myths in the population that are not contrasted by the professional in counselling. They complain that the method is imposed on them and that their views regarding the decision are not considered. Professionals are concerned that their lack of training leads to counselling directed towards the methods they know best. They acknowledge that a paternalistic paradigm persists in the healthcare they provide, and decision support tools may help to improve the situation.

Conclusions

Users feel unsatisfied and/or demand more information and a warmer, more caring approach. Professionals are reluctant to assume a process of shared decision-making. The use of a contraception DST website may solve some shortcomings in counselling detected in our environment.

In Spain, individuals can use a variety of contraceptive methods. Professionals involved in contraceptive counselling should help users to choose and properly use the method that best suits their preferences, personal situation and health status. However, there is a high number of unplanned pregnancies and the population feels dissatisfied with the counselling received. In the context of creating a website dealing with contraceptive methods, we wished to find out how counselling was taking place, giving voice those directly concerned. A qualitative study was proposed to explore the experiences and needs of users and professionals during counselling. Ten focus groups were conducted involving 64 users and 19 professionals from Tarragona (Spain). The results were ordered based on the Quality on Contraceptive Counseling (QCC) framework, created by experts, which determines what the relationship between user and professional should be like during the counselling process. Our analysis highlighted users’ little knowledge and false beliefs concerning contraception who, moreover, complained of receiving little information during counselling. They expressed their discontent with methods being imposed on them by the professional without exploring their preferences or needs. Meanwhile, the professionals argued that they often prescribe the method with which they are most familiar due to the lack of time during consultations at their office and/or because they are unfamiliar with other methods. These results, among others, offer the possibility of improving contraceptive counselling in Spain, if solutions to the difficulties and/or barriers detected are posed and implemented.

Latina contraceptive decision-making and use: The importance of provider communication and shared decision-making for patient-centered care

BACKGROUND

Poor patient-provider communication, among other reasons, is a notable barrier to contraceptive decision-making among Latinas. Patient-centered approaches to contraceptive counseling that optimize communication align with shared decision-making (SDM) -which is associated with satisfaction and continued contraceptive use among various populations.

OBJECTIVE

To examine associations of patient-provider communication and importance of SDM tenets with consistent contraceptive use among a population of Latinas.

PATIENT INVOLVEMENT

Formative work for this study included prior qualitative and quantitative research with Latinas who expressed the importance of patient-provider communication during contraceptive counseling and therefore were instrumental in problem definition.

METHODS

Cross-sectional surveys were administered to Latinas ages 15-29 years. Patient-provider communication, patient-reported importance of specific SDM tenets, and consistent contraception use were measured and analyzed for associations.

RESULTS

103 Latinas (mean age = 21.4) participated. 33% of participants<21 years were using contraception consistently vs. 67% for those ≥ 21 (p = 0.003). Among participants ≥ 21, consistent users reported higher communication scores compared to inconsistent users and non-users (p = 0.042). For participants< 21, consistent users were more likely than inconsistent users and non-users to report that 2 SDM tenets (discussion of contraceptive preferences and avoidance of race/ethnic-based judgement) are important (p = 0.052, 0.028, respectively).

DISCUSSION

Patient-provider communication was especially important for Latinas ≥ 21 while using an SDM approach during counseling was highly valued by those<21. Patient-centered approaches to contraceptive counseling provide opportunities to optimize healthcare delivery for this vulnerable population.

PRACTICAL VALUE

Results from this research demonstrate that patient-centered communication is highly valued by Latina study participants and is an important consideration in their contraceptive counseling. Clinicians should consider employing techniques such as SDM as they seek to provide patient-centered care during contraceptive counseling for this patient population.

Does cosmopolitan culture weaken ethnic and regional diversity: contraceptive behaviours of women in Istanbul, Turkey

OBJECTIVE

The primary aim of the study was to examine the relationship between self-reported ethnic identity, region of birth and contraceptive use, in Istanbul, Turkey.

METHODS

Cross-sectional data from a random sample of 3038 married women of reproductive age living in two urban districts of Istanbul were used in a series of logistic regression models to assess key relationships.

RESULTS

Kurdish ethnic minority women were less likely than Turkish ethnic majority women to use traditional contraceptive methods over no method (relative risk ratio [RRR] 0.69; 95% confidence interval [CI] 0.50, 0.96). However, there were no significant differences between ethnicities (i.e., Turkish, Kurdish and other) and modern method use. Among Turkish women, those born in regions farther away from the western region were more likely to use traditional methods (RRR_northern 2.06; 95% CI 1.31, 3.22).

CONCLUSION

While Kurdish ethnic minority women were less likely to use traditional methods, compared with Turkish ethnic majority women, the difference might have been due to the length of time living in a neighbourhood. Regional variations in contraceptive use were concentrated only among Turkish ethnic majority women and for traditional methods. Regional norms of traditional method use may be a barrier to modern contraceptive use in Turkey.

Structural Inequity and Pregnancy Desires in Emerging Adulthood

Public health discourses often claim that delaying pregnancy is associated with social and economic benefits. Yet research suggests that, for young people, structural inequity is most influential in future outcomes, regardless of childbearing. We conducted in-depth interviews with 50 young women (ages 18-24) and their male partners (n = 100) and investigated the influence of structural inequity on pregnancy desires and plans. Three themes emerged, stratified by social advantage. In the "Things Will Be Different Later" theme, socially advantaged participants envisioned that their future lives would surely be different due to achievement of educational, professional, and economic goals; thus, their pregnancy plans aligned with their desires, often reflected in use of highly effective contraception. In the "I Don't Have Everything I Need" theme, participants expressed delaying desired pregnancies (primarily through condom use) until they could contend with structural barriers. Their pregnancy plans, shifted by way of structural inequity, were not aligned with their desires. Under the "I'll Never Have Everything I Need" theme, socially disadvantaged participants expressed significant doubt about ever realizing ideal circumstances for pregnancy preparedness; as pregnancy prevention was not salient, these participants used condoms or no contraception. This analysis indicates that structural inequities constrain reproductive self-determination in emerging adulthood, creating a chasm between desired and actual childbearing that was reflected in contraceptive decision-making. Public health narratives emphasizing the importance of pregnancy prevention for socially disadvantaged groups without addressing the manifestation of structural inequity in their lives perpetuate reproductive oppression vis-à-vis emphasis on contraceptive use to ensure future economic success.

Racial and Ethnic Disparities in Receipt of Sexual Health Care and Education Among A Nationally Representative Sample of Adolescent Females

OBJECTIVE(S)

The USA has a high rate of adolescent pregnancy, with non-Hispanic (NH) Black and Hispanic women disproportionately affected. We sought to investigate the presence of racial/ethnic disparities in the receipt of sexual health (SRH) care and education and whether such disparities contribute to differences in sexual health outcomes for youth.

STUDY DESIGN

We conducted a cross-sectional study of females aged 15-21 years who participated in the National Survey of Family Growth from 2008 to 2015. Multivariable logistic regression was used to measure the association between race/ethnicity and SRH outcomes after adjustment for potential confounders. Models were developed to measure whether receipt of SRH care and education served as an effect modifier on SRH outcomes.

RESULTS

The sample included 4316 participants, representing 33.5 million females. Almost half (47.2%) received birth control services in the last 12 months; NH-Blacks (aOR 0.7 [0.5, 0.9]) and Hispanics (aOR 0.6 [0.5, 0.8]) were less likely to have obtained birth control services than NH-whites. Hispanics (aOR 1.5 [1.2, 1.9]) had a higher likelihood of receipt of condom education than NH-whites. We found that disparities in SRH outcomes were slightly mitigated after adjustment for access to SRH care and education.

CONCLUSIONS

We identified racial/ethnic disparities in sexual health outcomes and in SRH and education; however, SRH care and education can mitigate some of these differences in sexual behaviors and outcomes. Racial/ethnic differences in sexual health outcomes may be at least partially related to the differential receipt of sexual health care and education and deserve further investigation.

Contraindications to Hormonal Contraception Among Postpartum Women in Texas

OBJECTIVE

To examine the prevalence of contraindications to hormonal contraception among postpartum women.

METHODS

Low-income postpartum women who planned to delay childbearing for 2 years or longer after delivery were recruited for a prospective cohort study from eight Texas hospitals. Women self-reported health conditions that corresponded to category 3 and 4 contraindications to combined hormonal contraception and progestin-only methods, based on the Centers for Disease Control and Prevention's 2016 Medical Eligibility Criteria for Contraceptive Use. We used mixed-effects Poisson regression models to assess characteristics associated with reporting any contraindication 6 months after delivery. We examined the proportion of women who used a contraindicated method.

RESULTS

Of 1,452 women who completed the 6-month interview, 19.1% reported a category 3 or 4 contraindication to combined hormonal contraception (16.8% category 4) and 5.4% reported a contraindication to depot medroxyprogesterone acetate (0.1% category 4). Only 0.8% had any category 3 or 4 contraindication to progestin-only pills and 0.6% to the implant. Migraine with aura (12.4%) and hypertension (4.8%) were the most common contraindications. The prevalence of any contraindication was higher among women who were 30 years or older (prevalence ratio 1.45 95% CI 1.21-1.73), overweight (prevalence ratio 1.39, 95% CI 1.07-1.80), obese (prevalence ratio 1.55, 95% CI 1.16-2.07), and insured (prevalence ratio 1.34, 95% CI 1.04-1.74). Compared with U.S.-born Latina women, the prevalence of contraindications was higher among Black women (prevalence ratio 1.37, 95% CI 1.14-1.64) and lower among foreign-born Latina women (prevalence ratio 0.71, 95% CI 0.59-0.86). Among women with contraindications, 28 (10.3%) were using combined hormonal contraception; six (8%) were using a contraindicated progestin-only method.

CONCLUSION

Nearly one in five participants had a category 3 or 4 contraindication to combined hormonal contraception. Patients at higher risk for adverse birth outcomes are more likely to have contraindications. Clinicians should counsel on contraception and contraindications prenatally to facilitate the most informed postpartum decision.

Racial Disparities in Reproductive Healthcare among Parous and Nulliparous Women in Mississippi

BACKGROUND

Long-standing racial disparities exist in reproductive healthcare and have been associated with negative health outcomes among minority women. This study aimed to analyze the racial disparities in reproductive healthcare among Mississippi women, particularly as it related to contraception access, usage, setting, provider type, and payer.

METHODS

A two-stage stratified probability design was employed - 95 of the 1500 licensed childcare facilities across the state were randomly selected, and then two to three classrooms were randomly selected within each facility. The children were the means to obtaining a weighted sample of parous women of childbearing age (15-44). Once a parous woman completed the study, she could invite a nulliparous friend of similar age, race, and socioeconomic background to also participate in the study.

RESULTS

Racial disparities were found in the reproductive healthcare of both the parous and nulliparous groups. Overall, black women were less likely to receive services from an obstetrics and gynecology. Parous and nulliparous black women were more likely to receive their reproductive healthcare at the health department and less likely to use the most effective methods of contraception.

CONCLUSION

Low use of the most effective methods of contraception, despite high levels of general contraceptive use and high insurance coverage, hints at additional barriers to full access for black women in Mississippi. More equitable access to effective family planning counseling and contraception can have meaningful impact on the lives of black women in our state.

Contraceptive Decision Making Among Latina Immigrants: Developing Theory-Based Survey Items

BACKGROUND

Contraception is important for reproductive autonomy, yet many Latinas do not use contraception consistently despite research reporting a desire to do so. Factors varying in priority and value come into play during contraceptive decision making. When measuring these, relevant survey items may vary by populations.

AIM

This study focused on developing an ethnically responsive, patient-centered, content-valid survey for measuring factors that influence contraceptive decision making among immigrant Latinas.

METHOD

Nonpregnant self-identified Latinas ages 15 to 24 years in Baltimore, MD, were recruited from a family planning facility. Using the theory of planned behavior as a theoretical framework and prior formative research, initial survey items were drafted (Step 1). Content validation and cognitive interviewing procedures (Step 2 and Step 3) were used to develop final items.

RESULTS

Final items (27) were content-validated by the target population; items reflect important factors and relevant contexts affecting contraceptive decision making among Latinas in Baltimore.

DISCUSSION

These theory-based items provide an important contribution to the literature because they measure and explore factors related to contraceptive decision making in an understudied population. Providers might consider these factors during counseling to build patient-centered communication. These items might serve to measure responses to theory of planned behavior-based interventions designed to improve the contraceptive counseling of Latinas.

Building Strong Futures: The Feasibility of Using a Targeted Digital Media Campaign to Improve Knowledge About Pregnancy and Low Birthweight Among Black Women

Objective

Low birthweight is one of the main causes of poor health outcomes among newborns, with Black women having a disproportionately high prevalence. A digital intervention targeted Black women in Orange County, Florida with information on positive pregnancy-related knowledge and attitudes related to low birthweight. This paper reports on campaign methods for the first 2.5 years of implementation.

Methods

Campaign content was tailored toward Black women, around a reproductive empowerment lens. Content focused on emphasizing healthy pregnancy-related behaviors and creating positive representations of Black women throughout the various stages of pregnancy through both static images and a web series. Digital metrics gauged campaign engagement. Three cross-sectional online surveys conducted in the intervention county examined Black women’s pregnancy-related knowledge, attitudes, and behaviors.

Results

After two years of campaign implementation, social media accounts showed 1784 followers. While Facebook showed more average monthly impressions, Instagram showed more average monthly engagements. Survey results showed some increases in knowledge about prenatal care, weight gain, exercise, and the health impacts of low birthweight.

Conclusions for Practice

This study highlights the potential for a culturally-appropriate digital intervention to promote positive pregnancy outcomes among at-risk women. Digital interventions offer a potential way to achieve positive pregnancy-related behavior changes on a larger scale. This may be particularly important given that the COVID-19 pandemic may be changing the ways that pregnant women access information. Studies should examine the impact and feasibility of using culturally-appropriate digital interventions that directly address Black women and their specific experiences during pregnancy.

Racial/Ethnic Differences in Unwanted Pregnancy: Moderation by Sexual Orientation

OBJECTIVE

To explore sexual orientation disparities in unwanted pregnancy by race/ethnicity.

BACKGROUND

Previous research has documented that sexual-minority women (SMW) are more likely to report unplanned pregnancy than heterosexual women, and that Black and Latina women are more likely to report unplanned pregnancy than White women. No research has examined how pregnancy intention varies at the intersection of these two identities.

METHOD

Data come from the pregnancy roster data in Waves IV and Wave V subsample in the National Longitudinal Study of Adolescent to Adult Health. We used pregnancy as the unit of analysis (n=10,845) and multilevel logistic regression models to account for clustering of pregnancies within women. Per pregnancy, women were asked if they "wanted" to be pregnant at the time of pregnancy. We conducted models stratified by race/ethnicity, as well as models stratified by sexual identity.

RESULTS

Among White women, sexual-minority women were more likely to describe their pregnancy as unwanted than were their heterosexual counterparts. Conversely, among Black and Latina women, sexual-minority women were less likely to describe their pregnancy as unwanted than were their heterosexual counterparts. Results stratified by sexual identity underscore these contrasting patterns: Among heterosexual women, White women were less likely to describe their pregnancies as unwanted compared to Black and Latina women; among sexual-minority women, White women were more likely to describe their pregnancy as unwanted than were Black and Latina women.

CONCLUSION

Traditional race/ethnicity trends in pregnancy intention (i.e., greater unwanted pregnancy among Black/Latina than White women) are reversed among sexual-minority women.

Provider Counseling and Women's Family Planning Decisions in the Postpartum Period

Introduction: Provider counseling may influence women's postpartum family planning decisions. Materials and Methods: We conducted an anonymous Internet-based cross-sectional survey of postpartum women regarding multiple topics, including prenatal/postpartum care and family planning. We used multivariable logistic regression to determine associations between quantity of provider counseling (indexed as number of family planning topics discussed with a health care provider) and women's decisions regarding contraception and pregnancy spacing. Results: From January to May 2016, 2,850 women completed the survey and met inclusion criteria. Among this group, the majority were white (93%), ≥30 years (63%), and had obtained a college degree or higher (74%). Approximately half (49%) desired an interpregnancy interval (IPI) >2 years, and the minority (21%) used a highly effective contraceptive method (defined as long-acting reversible contraception or sterilization). The majority of women (56%) had received counseling on three to six family planning topics (defined as "more counseling" in regression models). Women who received more counseling were more likely to use a highly effective contraceptive method (adjusted odds ratio [AOR] 1.33, confidence interval [95% CI] 1.09-1.62) but were not more likely to desire an IPI >2 years (AOR 0.96, 95% CI 0.81-1.14). Desired IPI modified the association between provider counseling and contraception (p = 0.06 for interaction): Among those desiring an IPI >2 years, more counseling was associated with use of a highly effective contraceptive method (AOR 1.58, 95% CI 1.23-2.03), but this was not observed among those desiring a shorter IPI (AOR 1.05, 95% CI 0.73-1.49). Conclusions: Contraceptive decisions depend on both provider counseling and patient goals.

No Perfect Method: Exploring How Past Contraceptive Methods Influence Current Attitudes Toward Intrauterine Devices

Little research on contraceptive decision-making takes a holistic perspective to understand women's contraceptive journeys throughout the reproductive life course. This analysis investigated how Black and Latina women's past experiences with contraceptive use and acquisition impact their feelings and attitudes toward future use of intrauterine devices (IUDs). We utilized data from in-depth interviews that explored contraceptive decision-making and knowledge of, interest in, and attitudes toward IUDs among 38 young Black and Latina women collected in 2013 in the San Francisco Bay Area. Here, we focused on the IUD decision-making process among a subsample of 32 women who were not using or had not previously used an IUD. Overall, we found a strong link between past contraceptive experiences and attitudes regarding future use of IUDs. Notably, participants often referenced experiences of side effects with previous methods when explaining their interest-or lack thereof-in IUD use, as well as made links between contraceptive attributes they had experienced positively and attributes of the IUD. A minority of participants described being satisfied with their current method, resulting in a lack of interest in considering IUD use. More than half of participants described distrust, either in healthcare providers owing to previous negative interactions and contraceptive failures of provider-recommended methods or owing to family members' and friends' negative experiences with IUDs. This distrust undergirded their lack of interest in the IUD. These findings highlight the importance of locating contraceptive decision-making in the broader context of reproductive journeys.

Beyond same-day long-acting reversible contraceptive access: a person-centered framework for advancing high-quality, equitable contraceptive care

In the last decade-plus, there has been growing enthusiasm for long-acting reversible contraceptive methods as the solution to unintended pregnancy in the United States. Contraceptive access efforts have primarily focused on addressing provider and policy barriers to long-acting reversible contraception and have promoted long-acting reversible contraception as first-line methods through marketing and tiered-effectiveness counseling. A next generation of contraceptive access efforts has the opportunity to move beyond this siloed focus on long-acting reversible contraception toward a focus on equity and person-centeredness. Here we define a new framework for increasing equitable access to high-quality, person-centered contraceptive care that includes programmatic elements necessary to provide information and services to address the barriers to accessing quality care, organized into a four-part continuum. The continuum is contextualized within structural, systematic, and social factors that influence experience of contraceptive care. We aim to provide a practical framework for researchers, program implementers, and policy makers to develop and evaluate efforts to improve equitable access to and quality of contraceptive care. Initiatives can intentionally be cognizant of broader structural and social factors that will influence their success and the likelihood of negative unintended consequences for marginalized groups and thus deliberately work to design programs that meet all people's contraceptive needs and support reproductive autonomy.

Insights Into Provider Bias in Family Planning from a Novel Shared Decision Making Based Counseling Initiative in Rural, Indigenous Guatemala

Race, ethnicity, and indigenous status should be considered as potential drivers of provider bias in family planning services globally. Efforts to confront provider bias in family planning counseling should include concrete strategies that promote provider recognition of biases and longitudinal curriculums that allow for sustained feedback and self-reflection.

Challenging Stereotypes: A Counter-Narrative of the Contraceptive Experiences of Low-Income Latinas

Purpose: Reproductive autonomy is associated with educational attainment, advanced employment, and well-being. While U.S. Latinas use contraception to control their own childbearing and have reported a desire to do so, they often use it inconsistently and have the lowest rates of contraceptive use of any group. Reasons previously cited for why Latinas do not use contraception compared with non-Latino white women include lack of access, lack of knowledge, language barriers, emphasis on large families, machismo, and religiosity. These reasons are often overly simplistic and can lead to widespread generalizations about Latinas. Methods: Using focus groups and semistructured interviews from November 2014 through June 2015, this study describes the family planning perspectives and experiences of 16 Latinas living in Baltimore and recruited from two federally qualified health centers. A social determinant of health framework was used to guide identification of important concepts and explain findings. Results: Results demonstrated that respondents reported contraceptive agency and claimed autonomy over their bodies; described a sense of responsibility and often expressed caution about having families too large to care for; expressed educational and career aspirations; and perceived contraception as critical for the postponement of childbearing to achieve their goals. Conclusion: The patient/provider encounter should include communication that recognizes all patient preferences and lived experiences to support vulnerable and/or marginalized Latinas in their desires to control their own childbearing and life choices.

The association between religiosity and pregnancy acceptability among Latino/a young adults: does generational status matter?

The US Latino/a population is considered to be at high risk for unintended pregnancy; some research indicates that Latino/a parents are more likely to express happiness about an unintended pregnancy than other racial/ethnic groups. Associations between pregnancy attitudes and factors such as religiosity and nativity have also been documented in the Latino/a population, but existing research is sparse, dated and primarily focused on women of Mexican heritage. This study sought to expand this literature by examining the relationship between religiosity and pregnancy acceptability and assessing effect modification by generational status and gender in a national sample of young Latino/a cisgender women and men of various ancestral backgrounds currently in relationships. In multivariable logistic regression models, there was a positive association between importance of religion and pregnancy acceptability for both men and women; being highly or moderately religious was associated with elevated odds of finding a pregnancy acceptable. Effect modification by generational status was significant for women, but not for men. Results suggest that religiosity, gender and generational status have differential influences on and relationships to pregnancy orientations for Latina women and Latino men and should be considered in the design and delivery of family planning care for Latino/a clients.

Patient-provider communication before and after implementation of the contraceptive decision support tool My Birth Control

OBJECTIVE

To compare differences in patient-provider communication among patients who, prior to contraceptive counseling, used or did not use a decision support tool ("My Birth Control") which has educational and interactive modules and produces a provider printout with the patient's preferences.

METHODS

As part of a cluster-randomized trial of the tool in four San Francisco safety net clinics, we collected and thematically analyzed 70 audio recordings of counseling visits (31 pre- and 39 post-tool implementation) from 15 providers randomized to the intervention.

RESULTS

Without the tool, most providers began by asking participants what method they were considering and focused counseling on that method or on directing patients towards long-acting reversible contraception; with the tool, most focused on reviewing and discussing multiple methods of interest to the participant as indicated on the printout. Discussion of patients' preferences for specific method features was not observed in pre-implementation recordings but was part of several post-implementation recordings. Several participants explicitly noted they had gained knowledge from the tool.

CONCLUSION

Observed counseling differences suggest the tool may have a positive impact on patient-centeredness of contraceptive counseling, consistent with findings from the main study.

PRACTICE IMPLICATIONS

My Birth Control shows potential for improving patient-centeredness in counseling without extensive provider training.

Patient perceptions of immediate postpartum long-acting reversible contraception: A qualitative study

OBJECTIVES

The objective of this study was to explore perceptions and experiences of immediate postpartum long-acting reversible contraception (LARC) counseling and decision-making, with a focus on reproductive autonomy. We aimed to assess the potential for reproductive coercion.

STUDY DESIGN

This was a qualitative study using semi-structured interviews with Spanish and English speaking women who received an intrauterine device or contraceptive subdermal implant immediately postpartum. They were recruited before discharge from two hospitals in Baltimore, MD. We analyzed interviews using directed content analysis.

RESULTS

We interviewed a diverse group of 17 women. Participants praised the convenience of LARC and the ease of immediate postpartum placement. Some women reported feeling pushed by providers during counseling and were critical of their experiences. Women expressed a desire for comprehensive, objective information early and often during antepartum contraceptive counseling, and some valued counseling from multiple providers. They wanted autonomy in their contraceptive decision-making and described making internally motivated decisions based on their life goals and individual priorities.

CONCLUSIONS

Some women felt pressured to choose immediate postpartum LARC, while others expressed enthusiasm for immediate postpartum LARC. Our data suggest that providers should start contraceptive counseling early in prenatal care and readdress it at multiple visits. Patients may benefit from speaking with multiple providers.

IMPLICATIONS

Our study supports immediate postpartum LARC as a favorable contraceptive option for some women when discussed during prenatal care. Providers should take care to avoid coercion during counseling and focus on delivering comprehensive, objective information about all contraceptive methods, including side effects and removal options.

Risk factors and racial disparities related to low maternal birth satisfaction with labor induction: a prospective, cohort study

Background

Decreased birth satisfaction has been associated with labor induction. Yet, there is a paucity of data evaluating risk factors for decreased satisfaction associated with labor induction. We aimed to determine what factors impact low birth satisfaction in labor induction and evaluate racial disparities in birth satisfaction.

Methods

We performed a prospective cohort study of women with term, singleton gestations undergoing labor induction at our institution from Jan 2018 to Jun 2018. Women completed the validated Birth Satisfaction Scale-Revised postpartum, which is subdivided into 3 domains: (1) quality of care provision, (2) women’s personal attributes, and (3) stress experienced during labor. A total satisfaction score above the mean was classified as “satisfied”, and below as “unsatisfied.” Domain and item scores were compared by race.

Results

Three hundred thirty of 414 (79.7%) eligible women were included. There was no significant difference in birth satisfaction by age, body mass index, Bishop score, or labor induction agent. Black women were 75% more likely to be unsatisfied than non-Black women (54.0% vs. 37.2%, OR 1.75 [95% CI 1.11–2.76], p = 0.037), nulliparas were 71% more  likely to be unsatisfied than multiparas (54.2% vs. 40.9%, OR 1.71 [95% CI 1.09–2.67], p = 0.019), and women whose labor resulted in cesarean birth were almost 3 times more likely to be unsatisfied than women with a vaginal birth (67.4% vs. 42.3%, OR 2.82 [95% CI 1.69–4.70], p < 0.001). Additionally, increased labor length quartile was associated with decreased satisfaction >(p = 0.003). By race, domain 3 scores, which reflect preparedness for labor, were lower for Black women. No differences were seen for domain 1 or 2.

Conclusions

Black race, cesarean birth, and increasing labor length were identified as risk factors for low birth satisfaction among women who underwent labor induction. Further studies should explore interventions to target women at risk for low birth satisfaction.

The contraceptive needs and pregnancy desires of women after incarceration: A qualitative study

OBJECTIVE

Prior qualitative research with women incarcerated at Rikers Island Jail asked women to anticipate their future contraceptive needs and pregnancy desires upon re-entering the community. We conduct this follow-up study to understand better the actual contraceptive needs and pregnancy desires experienced by women after incarceration.

STUDY DESIGN

We conducted semi-structured in-depth interviews in New York City in 2014 with 10 women incarcerated within the past three years. We coded transcripts using an iterative process, identified emerging themes, and stopped recruitment after reaching thematic saturation.

RESULTS

Most participants desired to wait to become pregnant until they had stable housing, income, and employment. A few faced systemic barriers to obtaining contraception, including the process of re-applying for insurance and obtaining medical appointments. For many, incarceration disrupted their use of contraception, insurance status, and relationship with trusted medical providers. Most women lacked trust in the new health professionals they encountered after incarceration.

CONCLUSIONS

Incarceration disrupted medical care in general, and contraceptive care in particular. Assistance should be provided to re-apply for insurance, make appointments, and support women to see trusted health professionals.

IMPLICATIONS

Incarceration further disenfranchises an already marginalized community through disrupting access to medical care and constrains women's reproductive autonomy long after return to the community.

Quality of postpartum contraceptive counseling and changes in contraceptive method preferences

OBJECTIVES

We examined the association between quality of postpartum contraceptive counseling and changes in contraceptive method preference between delivery and 3-months postpartum.

STUDY DESIGN

We used data from 1167 postpartum women delivering at eight hospitals in Texas who did not initiate contraception in the hospital. We conducted baseline and 3-month follow-up interviews to ask women about the method they would prefer to use at 6-months postpartum, postpartum contraceptive counseling, reproductive history, and demographic characteristics. We measured quality of postpartum contraceptive counseling with seven items related to satisfaction and information received. High-quality counseling was defined as meeting all seven criteria. We used logistic regression to predict the primary outcome of changes in preferred method by contraceptive counseling and described contraceptive counseling and changes in preferred method by demographic characteristics.

RESULTS

Receipt of high-quality postpartum contraceptive counseling was reported by 26%. At 3-months postpartum 70% of participants reported the same contraceptive preferences by category of effectiveness that they expressed at the time of delivery. Spanish-speaking, Hispanic foreign-born, and lower socioeconomic status women were less likely to receive high-quality counseling than their counterparts. High-quality counseling was associated with lower odds of preferring a less effective method (OR: 0.31, 95% CI: 0.18-0.52) and changing preference from an IUD or implant (OR: 0.34, 95% CI: 0.17-0.68).

CONCLUSIONS

High-quality postpartum contraceptive counseling is relatively rare and occurs less often among low SES and immigrant women. High-quality counseling appears to reinforce preferences for effective contraception.

IMPLICATIONS

Training healthcare providers to provide high-quality contraceptive counseling to all postpartum women may reduce contraceptive disparities related to race/ethnicity and social class.

Contraceptive Desert? Black-White Differences in Characteristics of Nearby Pharmacies

OBJECTIVES

Race differences in contraceptive use and in geographic access to pharmacies are well established. We explore race differences in characteristics of nearby pharmacies that are likely to facilitate (or not) contraceptive purchase.

STUDY DESIGN

We conducted analyses with two geocode-linked datasets: (1) the Relationship Dynamics and Social Life (RDSL) project, a study of a random sample of 1003 women ages 18-19 living in a county in Michigan in 2008-09; and (2) the Community Pharmacy Survey, which collected data on 82 pharmacies in the county in which the RDSL study was conducted.

RESULTS

Although young African-American women tend to live closer to pharmacies than their white counterparts (1.2 miles to the nearest pharmacy for African Americans vs. 2.1 miles for whites), those pharmacies tend to be independent pharmacies (59 vs. 16%) that are open fewer hours per week (64.6 vs. 77.8) and have fewer female pharmacists (17 vs. 50%), fewer patient brochures on contraception (2 vs. 5%), more difficult access to condoms (49% vs. 85% on the shelf instead of behind glass, behind the counter, or not available), and fewer self-check-out options (3 vs. 9%). More African-American than white women live near African-American pharmacists (8 vs. 3%). These race differences are regardless of poverty, measured by the receipt of public assistance.

CONCLUSIONS

Relative to white women, African-American women may face a "contraception desert," wherein they live nearer to pharmacies, but those pharmacies have characteristics that may impede the purchase of contraception.

Cluster randomized trial of a patient-centered contraceptive decision support tool, My Birth Control

BACKGROUND

Research suggests the need for improvement in the patient-centeredness and comprehensiveness of contraceptive counseling. My Birth Control is a tablet-based decision support tool designed to improve women's experience of contraceptive counseling and to help them select contraceptive methods that are consistent with their values and preferences.

OBJECTIVE

The objective of this study was to evaluate the effect of My Birth Control on contraceptive continuation, experience of contraceptive care, and decision quality.

STUDY DESIGN

Using a cluster randomized design, randomized at the provider level, patient participants interested in starting or changing contraception interacted with My Birth Control before their family planning visit (intervention) or received usual care (control). A postvisit survey assessed experience of care method satisfaction, decision quality, and contraceptive knowledge. Surveys at 4 and 7 months assessed the primary outcome of contraceptive continuation, along with method use, satisfaction, and unintended pregnancy. Mixed-effects logistic regression models with multiple imputation for missing data were used to examine the effect of treatment assignment.

RESULTS

Twenty-eight providers participated and 758 patients enrolled between December 5, 2014, and February 5, 2016. Participants were racially/ethnically diverse; less than a quarter self-identified as white. No effect was found on 7-month continuation (56.6% and 59.6% for intervention and control group respectively, odds ratio, 0.89; 95% confidence interval, 0.65-1.22). However, assignment to the intervention group increased reporting of the greatest Interpersonal Quality of Family Planning score (66.0% vs 57.4%, odds ratio, 1.45; 95% confidence interval, 1.03-2.05), the greatest scores on the informed decision and uncertainty subscales of the Decisional Conflict Scale (50.5% vs 43.2%, odds ratio, 1.34; 95% confidence interval, 1.0-1.80 and 41.6% vs 33.3%, odds ratio, 1.45; 95% confidence interval, 1.03-2.05), and greater knowledge.

CONCLUSION

My Birth Control had no effect on contraceptive continuation. The intervention did enhance the experience of contraceptive counseling and informed decision making, as well as contraceptive knowledge., The intervention's effect on patient experience is important, particularly given the personal nature of contraceptive decision making and the social and historical context of family planning care.

Understanding Women Veterans' Family Planning Counseling Experiences and Preferences to Inform Patient-Centered Care

BACKGROUND

Women veterans' unique experiences in the military and burden of health comorbidities increase their risk of adverse pregnancy outcomes and may influence their counseling needs related to planning or preventing pregnancy. We investigated women veterans' experiences of family planning counseling in the military and Veterans Affairs (VA) health care systems as well as their counseling preferences.

METHODS

We conducted 32 qualitative interviews among women veterans ages 18-44 years receiving primary care at the VA Puget Sound or VA Pittsburgh health care systems between March and June 2016 to explore their experiences and preferences related to counseling about pregnancy goals and planning and contraception. Transcripts were analyzed using inductive and deductive content analysis, and key themes were identified.

RESULTS

Nearly all participants described negative experiences in family planning counseling encounters in the military and/or VA, including perceptions of gender-based discrimination and pressure to choose certain contraceptive methods, perceived judgment of their reproductive choices, and a lack of continuity with providers. Some women also reported positive experiences in family planning encounters in the VA, including feeling respected, receiving comprehensive information about options, and having their perspectives and concerns elicited. Counseling preferences that emerged included that providers initiate and validate family planning discussions, establish trust and avoid judgment, elicit women's individual preferences, and engage them as equal partners in decision making.

CONCLUSIONS

Women veterans reported a spectrum of negative and positive experiences in family planning encounters in the military and VA that, in conjunction with their preferences, provide key insights for patient-centered reproductive health care in VA.

Hormonal contraception, breastfeeding and bedside advocacy: the case for patient-centered care

Postpartum contraceptive decision making is complex, and recommendations may be influenced by breastfeeding intentions. While biologically plausible, concerns about the adverse impact of hormonal contraception on breast milk production have not been supported by the clinical evidence to date. However, the data have limitations, which can lead providers with different priorities around contraception and breastfeeding to interpret the data in a way that advances their personal priorities. Discrepancies in interpretations can lead to divergent recommendations for individual women and may cause conflict. Furthermore, providers must recognize that decision making about contraception and breastfeeding takes place in complex cultural, historical and socioeconomic contexts. Implicit bias may influence a provider's counseling. Unrecognized biases toward one patient or another, or one practice or another, may influence a provider's counseling. It is crucial for providers to strive to recognize their own biases. Providers need to respectfully recognize each patient's values and preferences regarding hormonal contraception and breastfeeding. Developing a patient-centered decision tool or implementing patient-centered interview techniques specifically around breastfeeding and contraception could help to minimize provider-driven variability in care.

Client Preferences for Contraceptive Counseling: A Systematic Review

CONTEXT

Providers can help clients achieve their personal reproductive goals by providing high-quality, client-centered contraceptive counseling. Given the individualized nature of contraceptive decision making, provider attention to clients' preferences for counseling interactions can enhance client centeredness. The objective of this systematic review was to summarize the evidence on what preferences clients have for the contraceptive counseling they receive.

EVIDENCE ACQUISITION

This systematic review is part of an update to a prior review series to inform contraceptive counseling in clinical settings. Sixteen electronic bibliographic databases were searched for studies related to client preferences for contraceptive counseling published in the U.S. or similar settings from March 2011 through November 2016. Because studies on client preferences were not included in the prior review series, a limited search was conducted for earlier research published from October 1992 through February 2011.

EVIDENCE SYNTHESIS

In total, 26 articles met inclusion criteria, including 17 from the search of literature published March 2011 or later and nine from the search of literature from October 1992 through February 2011. Nineteen articles included results about client preferences for information received during counseling, 13 articles included results about preferences for the decision-making process, 13 articles included results about preferences for the relationship between providers and clients, and 11 articles included results about preferences for the context in which contraceptive counseling is delivered.

CONCLUSIONS

Evidence from the mostly small, qualitative studies included in this review describes preferences for the contraceptive counseling interaction. Provider attention to these preferences may improve the quality of family planning care; future research is needed to explore interventions designed to meet preferences.

THEME INFORMATION

This article is part of a theme issue entitled Updating the Systematic Reviews Used to Develop the U.S. Recommendations for Providing Quality Family Planning Services, which is sponsored by the Office of Population Affairs, U.S. Department of Health and Human Services.