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Gero A, Elliott S, Baayd J, Cohen S, Simmons RG, Gawron LM. Factors associated with a negative Patient Acceptable Symptom State (PASS) response with intrauterine device placement: A retrospective survey of HER Salt Lake participants. Contraception 2024; 133:110385. [PMID: 38307487 DOI: 10.1016/j.contraception.2024.110385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 01/26/2024] [Accepted: 01/28/2024] [Indexed: 02/04/2024]
Abstract
OBJECTIVES In an established cohort of HER Salt Lake Contraceptive Initiative participants with a prior intrauterine device (IUD) placement, we sought to (1) define the proportion of participants who reported a negative Patient Acceptable Symptom State (PASS) response, (2) explore factors associated with an unacceptable PASS response, and (3) identify pain management preferences for IUD placement. STUDY DESIGN A retrospective survey was sent to 1440 HER Salt Lake IUD users. A PASS question queried IUD placement pain experience acceptability. We explored associations between an unacceptable PASS response and sociodemographic, reproductive and other individual characteristics using t-tests, chi-square tests, and multivariable logistic regression. RESULTS Of those surveyed, 620 responded (43%), and 41.6% reported an unacceptable PASS response. Those with an unacceptable PASS response reported a significantly higher experienced pain level (79.2 mm vs 51.8 mm; p < 0.01) than those with an acceptable response, were more likely to have an anxiety diagnosis (47.7% vs 37.1%; p < 0.01), and have a trauma history (33.7% vs 25.1%; p = 0.02). Most patients were not offered pain control options, but 29.4% used ibuprofen and 25.3% had a support person. Regardless of PASS response, if offered, 59.0% desired numbing medication, 56.8% ibuprofen, 51% heating pad, 33.2% support person, and 31.8% anti-anxiety medication, among others. In our multivariable logistic regression model, higher pain was associated with unacceptable PASS response (OR 1.07, 95% CI 1.05-1.08; p < 0.01). CONCLUSIONS The common finding of unacceptable pain experiences with IUD placement may cause negative perceptions of an otherwise desirable method. Incorporation of the PASS response into IUD pain management studies could expand our pain experience understanding. IMPLICATIONS IUD placement resulted in unacceptable pain experiences for 41.6% of respondents. Screening for anxiety and trauma history could identify at-risk patients to individualize pain management strategies. Incorporation of the PASS into future IUD pain management studies could result in a more comprehensive, patient-centered measure of patient experiences.
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Affiliation(s)
- Alexandra Gero
- ASCENT Center for Reproductive Health, Family Planning Division, Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Sarah Elliott
- ASCENT Center for Reproductive Health, Family Planning Division, Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Jami Baayd
- ASCENT Center for Reproductive Health, Family Planning Division, Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Susanna Cohen
- ASCENT Center for Reproductive Health, Family Planning Division, Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Rebecca G Simmons
- ASCENT Center for Reproductive Health, Family Planning Division, Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Lori M Gawron
- ASCENT Center for Reproductive Health, Family Planning Division, Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, UT, United States.
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Gawron LM, Kaiser JE, Gero A, Sanders JN, Johnstone EB, Turok DK. Pharmacodynamic evaluation of the etonogestrel contraceptive implant initiated midcycle with and without ulipristal acetate: An exploratory study. Contraception 2024; 132:110370. [PMID: 38232940 PMCID: PMC10922844 DOI: 10.1016/j.contraception.2024.110370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 01/08/2024] [Accepted: 01/10/2024] [Indexed: 01/19/2024]
Abstract
OBJECTIVE To estimate the incidence of ovulation suppression within five days of etonogestrel 68 mg implant insertion in the presence of a dominant follicle with and without same-day ulipristal acetate. STUDY DESIGN This single site non-masked, exploratory randomized trial recruited people age 18-35 years with regular menstrual cycles, no pregnancy risk, and confirmed ovulatory function. We initiated transvaginal ultrasound examinations on menstrual day 7-9 and randomized participants 1:1 to etonogestrel implant alone or with concomitant ulipristal acetate 30 mg oral when a dominant follicle reached ≥14 mm in diameter. We completed daily sonography and serum hormone levels for up to seven days or transitioned to labs alone if sonographic follicular rupture occurred. We defined ovulation as follicular rupture followed by progesterone >3 ng/mL. We calculated point estimates, risk ratios and 95% confidence intervals for ovulation for each group. Ovulation suppression of ≥44% in either group (the follicular rupture suppression rate with oral levonorgestrel emergency contraception), would prompt future method testing. RESULTS From October 2020 to October 2022, we enrolled 40 people and 39 completed primary outcome assessments: 20 with etonogestrel implant alone (mean follicular size at randomization: 15.2 mm ± 0.9 mm) and 19 with etonogestrel implant + ulipristal acetate (mean follicular size at randomization: 15.4 mm ± 1.2 mm, p = 0.6). Ovulation suppression occurred in 13 (65%) of etonogestrel implant-alone participants (Risk ratio 0.6 (95% CI: 0.3, 1.1), p = 0.08) and seven (37%) of implant + ulipristal acetate participants. CONCLUSIONS Ovulation suppression of the etonogestrel implant alone exceeds threshold testing for future research while the implant + ulipristal acetate does not. IMPLICATIONS Data are lacking on midcycle ovulation suppression for the etonogestrel implant with and without oral ulipristal acetate. In this exploratory study, ovulation suppression occurred in 65% of implant participants and 37% of implant + ulipristal acetate participants. Ovulation suppression of the implant alone exceeds threshold testing for future emergency contraception research.
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Affiliation(s)
- Lori M Gawron
- Division of Family Planning, Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT, USA.
| | - Jennifer E Kaiser
- Division of Family Planning, Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT, USA
| | - Alexandra Gero
- Division of Family Planning, Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT, USA
| | - Jessica N Sanders
- Division of Family Planning, Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT, USA
| | - Erica B Johnstone
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT, USA
| | - David K Turok
- Division of Family Planning, Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT, USA
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Gawron LM, Sexsmith CD, Carter G, Kaiser JE, Pangasa M, Turok DK. Efficacy of oral levonorgestrel emergency contraception with same day etonogestrel contraceptive implant: A prospective observational study. Contraception 2024; 131:110344. [PMID: 38008305 PMCID: PMC10872399 DOI: 10.1016/j.contraception.2023.110344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 11/21/2023] [Accepted: 11/22/2023] [Indexed: 11/28/2023]
Abstract
OBJECTIVE To determine a 1-month pregnancy rate point estimate and 95% confidence interval for guideline-supported, same-day initiation of an etonogestrel implant plus oral levonorgestrel emergency contraception. STUDY DESIGN In this single-arm, prospective observational study, all emergency contraception clients who presented to four Planned Parenthood Association of Utah clinics from February 2021 to March 2023 received information about oral levonorgestrel with same-day etonogestrel implant insertion. Participants were ≤35 years and reported unprotected intercourse within 5 days with negative pregnancy testing. The primary outcome measure was a 1-month home pregnancy test. We calculated the efficacy using a test of proportions with Yates continuity correction. RESULTS A total of 160 emergency contraception clients (7.6% of 2106 approached) enrolled and 153 had 1-month pregnancy outcomes. A positive pregnancy test occurred in 2 participants resulting in an overall pregnancy rate of 1.32% (95% confidence interval 0.23%-5.19%). Ultrasound gestational dating assigned conception of the first pregnancy to 8 days before enrollment. For the second pregnancy, ultrasound dating designated conception at 5 days prior to enrollment. Limiting the efficacy rate to the single pregnancy that occurred within 5 days of unprotected intercourse, we report a pregnancy rate of 0.66% (95% confidence interval 0.03%-4.19%). CONCLUSIONS In this observational study of emergency contraception clients selecting oral levonorgestrel with same-day etonogestrel implant, we identified a pregnancy rate within the established range of oral emergency contraception methods alone. IMPLICATIONS Clients presenting for emergency contraception may also desire ongoing highly-effective contraception, yet current clinical guidelines serve as a barrier to same-day method initiation for the etonogestrel implant and other hormonal methods. Improving access to contraceptive method initiation will reduce the ongoing risk of unwanted pregnancy for this population. CLINICAL TRIAL REGISTRATION Clinicaltrials.gov NCT04678817; registered 12/16/20.
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Affiliation(s)
- Lori M Gawron
- ASCENT Center for Reproductive Health, Family Planning Division, Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, UT, United States.
| | - Corinne D Sexsmith
- ASCENT Center for Reproductive Health, Family Planning Division, Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Gentry Carter
- ASCENT Center for Reproductive Health, Family Planning Division, Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Jennifer E Kaiser
- ASCENT Center for Reproductive Health, Family Planning Division, Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Misha Pangasa
- ASCENT Center for Reproductive Health, Family Planning Division, Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - David K Turok
- ASCENT Center for Reproductive Health, Family Planning Division, Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, UT, United States
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Panushka KA, Kozlowski Z, Dalessandro C, Sanders JN, Millar MM, Gawron LM. "It's Not a Top Priority": A Qualitative Analysis of Provider Views on Barriers to Reproductive Healthcare Provision for Homeless Women in the United States. Soc Work Public Health 2023; 38:428-436. [PMID: 38361354 PMCID: PMC10908250 DOI: 10.1080/19371918.2024.2315180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
Women experiencing housing insecurity are at an elevated risk for adverse reproductive health outcomes due to the prevalence of chronic health conditions and higher risk behaviors. Social service and healthcare providers are front line in addressing women's needs when they seek support. Thus, we sought to explore reproductive healthcare barriers using in-depth interviews with 17 providers at 11 facilities serving housing-insecure women in Salt Lake County, Utah, USA from April to July 2018. Providers noted a number of system-, provider-, and individual-level barriers. Dominant themes include reliance on unstable funding, lack of provider training on reproductive health, and perceived logistical challenges to care. Due to the prevalence of immediate needs among housing-insecure women, providers attest that reproductive health needs often do not emerge as their urgent concern. Our findings suggest that addressing policy and funding challenges to prioritizing reproductive needs among housing-insecure women can help mitigate the potential for long-term adverse reproductive outcomes.
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Affiliation(s)
| | - Zoe Kozlowski
- School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Cristen Dalessandro
- Division of Family Planning, Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT, USA
| | - Jessica N. Sanders
- Division of Family Planning, Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT, USA
| | - Morgan M. Millar
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - Lori M. Gawron
- Division of Family Planning, Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT, USA
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Woodcock AL, Carter G, Baayd J, Turok DK, Turk J, Sanders JN, Pangasa M, Gawron LM, Kaiser JE. Effects of the Dobbs v Jackson Women's Health Organization Decision on Obstetrics and Gynecology Graduating Residents' Practice Plans. Obstet Gynecol 2023; 142:1105-1111. [PMID: 37769302 DOI: 10.1097/aog.0000000000005383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 08/03/2023] [Indexed: 09/30/2023]
Abstract
OBJECTIVE To explore the association of the Dobbs v Jackson Women's Health Organization ( Dobbs ) decision on future practice locations of graduating obstetrics and gynecology residents. METHODS This is a mixed-methods survey study of obstetrics and gynecology residents graduating from sites with Ryan Program abortion training programs (109 sites) between March 8, 2023, and April 25, 2023. We conducted both univariate and multivariable logistic regression analyses to identify factors that were associated with post- Dobbs change in career plans, particularly location. We also performed a thematic analysis using responses to the survey's optional, open-ended prompt, "Please describe how the Dobbs v Jackson Women's Health Organization decision impacted your professional plans." RESULTS Of an estimated 724 residents graduating from residencies with Ryan Program abortion training programs, 349 participated in the survey (48.2% response rate); 17.6% of residents indicated that the Dobbs decision changed the location of intended future practice or fellowship plans. Residents who before the Dobbs decision intended to practice in abortion-restrictive states were eight times more likely to change their practice plans than those who planned to practice in protected states before the Dobbs decision (odds ratio 8.52, 95% CI 3.81-21.0). In a thematic analysis of open-ended responses, 90 residents wrote responses related to "not living in a state with abortion restrictions." Of residents pursuing fellowship, 36 indicated that they did not rank or ranked lower programs in restrictive states. CONCLUSION These findings demonstrate reduced desire of residents in obstetrics and gynecology to practice or pursue fellowship in restrictive states after residency. This reduction in obstetrics and gynecology workforce could significantly exacerbate maternity care deserts.
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Affiliation(s)
- Alexandra L Woodcock
- Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, Utah; and Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, Bixby Center for Global Reproductive Health, San Francisco, California
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Mahorter S, Vinekar K, Shaw JG, Mor MK, Pleasure ZH, Gawron LM, Callegari LS. Variations in Provision of Long-Acting Reversible Contraception Across Veterans Health Administration Facilities. J Gen Intern Med 2023:10.1007/s11606-023-08123-5. [PMID: 37340270 DOI: 10.1007/s11606-023-08123-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Accepted: 02/24/2023] [Indexed: 06/22/2023]
Affiliation(s)
- Siobhan Mahorter
- Health Services Research & Development (HSR&D) Seattle-Denver Center of Innovation for Veteran Centered & Value Driven Care, Department of Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, USA
| | - Kavita Vinekar
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Department of Obstetrics & Gynecology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Jonathan G Shaw
- VA HSR&D Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, CA, USA
- Division of Primary Care & Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - Maria K Mor
- VA HSR&D Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA
| | - Zoe H Pleasure
- Health Services Research & Development (HSR&D) Seattle-Denver Center of Innovation for Veteran Centered & Value Driven Care, Department of Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, USA
- Department of Health Systems & Population Health, University of Washington School of Public Health, Seattle, WA, USA
| | - Lori M Gawron
- Health Services Research & Development, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Department of Obstetrics & Gynecology, University of Utah, Salt Lake City, UT, USA
| | - Lisa S Callegari
- Health Services Research & Development (HSR&D) Seattle-Denver Center of Innovation for Veteran Centered & Value Driven Care, Department of Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, USA.
- Department of Health Systems & Population Health, University of Washington School of Public Health, Seattle, WA, USA.
- Department of Obstetrics & Gynecology, University of Washington School of Medicine, Seattle, WA, USA.
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Creinin MD, Barnhart KT, Gawron LM, Eisenberg D, Mabey RG, Jensen JT. Heavy Menstrual Bleeding Treatment With a Levonorgestrel 52-mg Intrauterine Device. Obstet Gynecol 2023; 141:971-978. [PMID: 37023455 PMCID: PMC10108838 DOI: 10.1097/aog.0000000000005137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 01/12/2023] [Indexed: 04/08/2023]
Abstract
OBJECTIVE To evaluate heavy menstrual bleeding treatment outcomes with levonorgestrel 52-mg intrauterine device (IUD) use in participants without body mass index (BMI) or parity restrictions. METHODS Investigators included participants aged 18-50 years with no pelvic or systemic pathology causing heavy menstrual bleeding at 29 U.S. centers in a prospective trial. Participants had up to three screening cycles with menstrual product collection for alkaline hematin blood-loss measurements. Investigators enrolled those with two menses with blood loss of 80 mL or more (values averaged for baseline blood loss), placed the IUD, and followed participants for up to six 28-day cycles. Participants collected any menstrual products used during cycles 3 and 6 for blood-loss measurement. We evaluated outcomes in participants with at least one follow-up assessment for the primary outcome of median absolute blood-loss change and, secondarily, treatment success, defined as the proportion with a final measured blood loss less than 80 mL and at least 50% reduction from baseline. We evaluated exploratory outcomes of differences in blood-loss changes by BMI and parity using Wilcoxon rank sum test. RESULTS Of 105 enrolled participants, 47 (44.8%) had obesity (BMI 30.0 or higher) and 29 (27.6%) were nulliparous. Baseline mean blood loss ranged from 73 to 520 mL (median 143 mL, interquartile range 112-196 mL). Eighty-nine (84.8%) had at least one evaluable follow-up evaluation. Participants had median (interquartile range) absolute blood-loss decreases at cycles 3 (n=86) and 6 (n=81) of 93.3% (86.1-97.7%) and 97.6% (90.4-100%), respectively. At cycle 6, participants without obesity (n=43) and with obesity (n=38) had similar median [interquartile range] decreases (97.6% [91.8-100%] and 97.5% [90.3-100%], respectively; P=.89), with comparable findings for nulliparous (n=25) and parous (n=56) participants (97.0% [91.7-99.1%] and 98.1% [89.9-100%], respectively; P=.43). Treatment success occurred in 81.8% (95% CI 74.2-89.4%) of 99 participants, excluding those with no outcomes due to lost to follow-up or consent withdrawal, and did not vary by BMI or parity. The most common adverse events leading to discontinuation were bleeding or cramping (n=6 [5.7%]) and expulsion (n=5 [4.8%]). CONCLUSION This levonorgestrel 52-mg IUD reduces blood loss by more than 90% over 6 months compared with baseline for most users with heavy menstrual bleeding. FUNDING SOURCE Medicines360. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov, NCT03642210.
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Affiliation(s)
- Mitchell D Creinin
- Department of Obstetrics and Gynecology, University of California, Davis, Sacramento, California; the Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania; the Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah; the Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, Missouri; Las Vegas, Nevada; and the Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon
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Kaiser JE, Turok DK, Gero A, Gawron LM, Simmons RG, Sanders JN. One-year pregnancy and continuation rates after placement of levonorgestrel or copper intrauterine devices for emergency contraception: a randomized controlled trial. Am J Obstet Gynecol 2023; 228:438.e1-438.e10. [PMID: 36427600 PMCID: PMC10065890 DOI: 10.1016/j.ajog.2022.11.1296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 11/08/2022] [Accepted: 11/17/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Recent evidence demonstrates the effectiveness of the levonorgestrel 52-mg intrauterine device for emergency contraception vs the copper T380A intrauterine device. Of note, 1-year pregnancy and continuation rates after intrauterine device placement for emergency contraception remain understudied. OBJECTIVE This study compared 1-year pregnancy and intrauterine device continuation rates and reasons for discontinuation among emergency contraception users randomized to the levonorgestrel 52-mg intrauterine device or the copper intrauterine device. STUDY DESIGN This participant-masked, randomized noninferiority trial recruited emergency contraception individuals desiring an intrauterine device from 6 Utah family planning clinics between August 2016 and December 2019. Participants were randomized 1:1 to the levonorgestrel 52-mg intrauterine device group or the copper T380A intrauterine device group. Treatment allocation was revealed to participants at the 1-month follow-up. Trained personnel followed up the participants by phone, text, or e-mail at 5 time points in 1 year and reviewed electronic health records for pregnancy and intrauterine device continuation outcomes for both confirmation and nonresponders. We assessed the reasons for the discontinuation and used Cox proportional-hazard models, Kaplan-Meier estimates, and log-rank tests to assess differences in the continuation and pregnancy rates between the groups. RESULTS The levonorgestrel and copper intrauterine device groups included 327 and 328 participants, respectively, receiving the respective interventions. By intention-to-treat analysis at 1 year, the pregnancy rates were similar between intrauterine device types (2.8% [9/327] in levonorgestrel 52-mg intrauterine device vs 3.0% [10/328] in copper intrauterine device; risk ratio, 0.9; 95% confidence interval, 0.4-2.2; P=.82). Most pregnancies occurred in participants after intrauterine device removal, with only 1 device failure in each group. Of note, 1-year continuation rates did not differ between groups with 204 of 327 levonorgestrel 52-mg intrauterine device users (62.4%) and 183 of 328 copper T380A intrauterine device users (55.8%) continuing intrauterine device use at 1 year (risk ratio, 1.1; 95% confidence interval, 1.0-1.2; P=.09). There were differences concerning the reasons for discontinuation between intrauterine device types, with more bleeding and cramping cited among copper intrauterine device users. CONCLUSION The pregnancy rates were low and similar between intrauterine device types. Of note, 6 of 10 intrauterine device emergency contraception users continued use at 1 year. Moreover, 1-year continuation rates were similar between intrauterine device types.
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Affiliation(s)
- Jennifer E Kaiser
- Division of Family Planning, Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT.
| | - David K Turok
- Division of Family Planning, Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT
| | - Alexandra Gero
- Division of Family Planning, Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT
| | - Lori M Gawron
- Division of Family Planning, Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT
| | - Rebecca G Simmons
- Division of Family Planning, Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT
| | - Jessica N Sanders
- Division of Family Planning, Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT
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Gawron LM, Young J, Yang S, Galyean P, Callegari LS, Gero A, Simmons RG, Millar MM, Zickmund SL. Women's Health Provider Perspectives on Reproductive Services Provision in the Veterans Health Administration. South Med J 2023; 116:181-187. [PMID: 36724533 PMCID: PMC9906969 DOI: 10.14423/smj.0000000000001513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVES Women veterans are a fast-growing population in the Veterans Health Administration (VHA), and ensuring reproductive service availability is a VHA priority. As such, we sought to explore barriers and facilitators to VHA reproductive service provision across a catchment area from women's health providers' perspectives. METHODS We performed a mixed-methods study, including semistructured, qualitative provider interviews with a quantitative survey on training, comfort, and knowledge of reproductive services. All women's health providers and their support staff from the Salt Lake City Veterans Affairs Medical Center and nine VHA community-based outpatient clinics were asked to participate. We conducted qualitative interviews and knowledge surveys with providers and staff to explore training, care processes, and improvement opportunities in reproductive service provision. We completed descriptive analyses of all of the quantitative data and used an open, iterative process to analyze provider interviews for emergent themes. RESULTS We interviewed 15 providers (7 advanced practice nurses, 4 registered nurses, and 4 physicians) across nine sites (50% response rate). The commonly identified barriers included provider training and staffing, scheduling/referral processes, inconsistent services/supplies, and lack of veteran awareness of reproductive services. Facilitators included prior non-VHA reproductive health experience among providers, invested support staff, and the integrated VHA health system. CONCLUSIONS Addressing barriers to VHA reproductive healthcare provision may overcome reproductive service variations related to clinic location and improve reproductive health outcomes for women veterans.
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Affiliation(s)
| | | | | | | | | | - Alexandra Gero
- From the Department of Obstetrics and Gynecology, Division of Family Planning, University of Utah, Salt Lake City
| | - Rebecca G Simmons
- From the Department of Obstetrics and Gynecology, Division of Family Planning, University of Utah, Salt Lake City
| | - Morgan M Millar
- the Department of Internal Medicine, Division of Epidemiology, University of Utah, Salt Lake City
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Kaiser JE, Kurtz T, Glasser A, Brintz BJ, Gawron LM, Turok DK, Sanders JN. Mifepristone for miscarriage treatment in Utah: A survey of clinician knowledge and assessment of an educational video on future use. AEM Educ Train 2022; 6:e10834. [PMID: 36562027 PMCID: PMC9764035 DOI: 10.1002/aet2.10834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 11/07/2022] [Accepted: 11/14/2022] [Indexed: 06/17/2023]
Abstract
Objectives We aimed to: (a) describe current use of mifepristone for early pregnancy loss (EPL) management in Utah, (b) identify predictors of knowledge pre- and posteducational video, and (c) explore postvideo impacts on the likelihood to use mifepristone. Mifepristone is subject to the Food and Drug Administration's (FDA) Risk Evaluation and Mitigation Strategy (REMS) requirements. Methods Between September 2020 and March 2021 we surveyed Utah clinicians from six specialties caring for people experiencing EPL, recruited through professional organizations and hospital listservs. Participants viewed a 3.5-minute educational video on mifepristone for EPL and completed pre- and postvideo questionnaires. We evaluated predictors of high prevideo and improved postvideo knowledge using random forest regression conditional importance measures and partial dependency plots. We described current mifepristone use and video effects on likelihood to use mifepristone. Results Of 506 participants, most specialize in emergency medicine (172, 34%) and practice in private settings (253, 51%). Two-thirds had heard of mifepristone (328/471, 70%). Of 176/471 (37%) attempting provision of mifepristone, actual provision occurred for 59% (104/176). Baseline knowledge scores were low (mean 4.81/13 [37%] correct). Predictors of high prevideo knowledge include provision or attempted provision of mifepristone, having heard of mifepristone, providing EPL management expectantly or via medication, and specialty type. Mean postvideo knowledge scores improved by 3.27 points (68% improvement, paired t-test; 95% confidence interval 2.82-3.72, p < 0.0001). Postvideo, 66% (242/364) stated they are much more or somewhat more likely to use mifepristone, with compliance with FDA requirements cited as a barrier to utilization. Conclusions Among Utah providers, baseline mifepristone knowledge and use for EPL management are low. An educational video improved knowledge and likelihood of use, but FDA REMS requirements continue to be a barrier to including mifepristone in medication management of EPL.
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Affiliation(s)
- Jennifer E. Kaiser
- Division of Family Planning, Department of Obstetrics and GynecologyUniversity of UtahSalt Lake CityUtahUSA
| | - Theresa Kurtz
- Department of Obstetrics and GynecologyUniversity of UtahSalt Lake CityUtahUSA
| | - Annabah Glasser
- University of Utah Spencer Eccles School of MedicineSalt Lake CityUtahUSA
| | - Benjamin J. Brintz
- University of Utah, Study Design and Biostatistics CenterSalt Lake CityUtahUSA
| | - Lori M. Gawron
- Division of Family Planning, Department of Obstetrics and GynecologyUniversity of UtahSalt Lake CityUtahUSA
| | - David K. Turok
- Division of Family Planning, Department of Obstetrics and GynecologyUniversity of UtahSalt Lake CityUtahUSA
| | - Jessica N. Sanders
- Division of Family Planning, Department of Obstetrics and GynecologyUniversity of UtahSalt Lake CityUtahUSA
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Clement AC, Turok DK, Gawron LM, Sanders JN. P082Rural-urban differences in post-abortion contraception use and past contraceptive access: A cohort study of abortion patients in utah. Contraception 2022. [DOI: 10.1016/j.contraception.2022.09.106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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12
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Gawron LM, Gero A, Sanders JN, Clement A, Pangasa M, Turok DK. P060Utilization of larc methods at the time of emergency contraception visit: A prospective observational study. Contraception 2022. [DOI: 10.1016/j.contraception.2022.09.084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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13
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Kerestes C, Tschann M, Shapiro MP, Berry E, Gawron LM, Kaneshiro B. O08Self-determination of eligibility for early medication abortion without ultrasound using a history-based tool — lmp-sure. Contraception 2022. [DOI: 10.1016/j.contraception.2022.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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14
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Callegari LS, Benson SK, Mahorter SS, Nelson KM, Arterburn DE, Hamilton AB, Taylor L, Hunter-Merrill R, Gawron LM, Dehlendorf C, Borrero S. Evaluating the MyPath web-based reproductive decision support tool in VA primary care: Protocol for a pragmatic cluster randomized trial. Contemp Clin Trials 2022; 122:106940. [PMID: 36179982 DOI: 10.1016/j.cct.2022.106940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 09/22/2022] [Accepted: 09/23/2022] [Indexed: 01/27/2023]
Abstract
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.
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Affiliation(s)
- Lisa S Callegari
- Health Services Research and Development, Department of Veterans Affairs (VA) Puget Sound Health Care System, Seattle, USA; Department of Obstetrics & Gynecology, University of Washington School of Medicine, Seattle, USA; Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, USA.
| | - Samantha K Benson
- Health Services Research and Development, Department of Veterans Affairs (VA) Puget Sound Health Care System, Seattle, USA
| | - Siobhan S Mahorter
- Health Services Research and Development, Department of Veterans Affairs (VA) Puget Sound Health Care System, Seattle, USA
| | - Karin M Nelson
- Health Services Research and Development, Department of Veterans Affairs (VA) Puget Sound Health Care System, Seattle, USA; Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, USA; Department of Medicine, University of Washington School of Medicine, Seattle, USA
| | - David E Arterburn
- Kaiser Permanente Washington Health Research Institute, Seattle, USA
| | - Alison B Hamilton
- Health Services Research and Development, VA Greater Los Angeles Healthcare System, Los Angeles, USA; Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, USA
| | - Leslie Taylor
- Health Services Research and Development, Department of Veterans Affairs (VA) Puget Sound Health Care System, Seattle, USA
| | - Rachel Hunter-Merrill
- Health Services Research and Development, Department of Veterans Affairs (VA) Puget Sound Health Care System, Seattle, USA
| | - Lori M Gawron
- Health Services Research and Development, VA Salt Lake City Health Care System, Salt Lake City, USA; Department of Obstetrics & Gynecology, University of Utah School of Medicine, Salt Lake City, USA
| | - Christine Dehlendorf
- Department of Family and Community Medicine, University of California San Francisco School of Medicine, San Francisco, USA
| | - Sonya Borrero
- Center for Health Equity, Research, and Promotion, VA Pittsburgh Health Care System, Pittsburgh, USA; Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, USA
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15
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Gawron LM, He T, Lewis L, Fudin H, Callegari LS, Turok DK, Stevens V. Oral Emergency Contraception Provision in the Veterans Health Administration: a Retrospective Cohort Study. J Gen Intern Med 2022; 37:685-689. [PMID: 36042074 PMCID: PMC9481759 DOI: 10.1007/s11606-022-07596-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 04/01/2022] [Indexed: 10/31/2022]
Abstract
BACKGROUND In the USA, oral emergency contraception (EC) use to prevent unintended pregnancy is increasing. Oral EC methods include levonorgestrel (LNG) and ulipristal acetate (UPA), with increased UPA efficacy over LNG in high BMI users and those beyond 3 days post intercourse. The Veterans Health Administration (VHA) provides oral EC at low or no cost, yet prescription-level Veteran data are lacking. OBJECTIVE To describe oral EC provision in VHA, including method type and Veteran user and prescriber characteristics. DESIGN A retrospective cohort study using VHA administrative data. PARTICIPANTS All VHA oral EC prescriptions from January 1, 2016, to December 31, 2020. MAIN MEASURES We linked Veteran-level sociodemographic and military characteristics and provider-level data with each prescription to identify variables associated with oral EC method. KEY RESULTS A total of 4280 EC prescriptions (85% LNG) occurred for 3120 unique Veterans over 5 years. While prescriptions remained low annually, the proportion of UPA prescriptions increased from 12 to 19%. Compared to LNG users, UPA users were older (34% vs 25% over age 35 years, p <0.001); more likely to identify as white (57% vs 46%) and non-Hispanic (84% vs 79%) (p <0.001); and more likely to have a BMI ≥ 25 (76% vs 67%, p <0.001). UPA prescriptions originated most frequently from VA Medical Centers (87%) and women's health clinics (76%) compared to community-based or other clinic types. In multivariable regression models, race, ethnicity, BMI ≥30, and prescriber facility type of a VA Medical Center or a women's clinic location were predictive of UPA prescription. CONCLUSIONS Oral EC provision in VHA remains low, but UPA use is increasing. LNG prescription occurs frequently in high BMI Veterans who would benefit from increased efficacy of UPA. Interventions to expand oral EC access in VHA are essential to ensure Veterans' ability to avert unwanted pregnancies.
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Affiliation(s)
- Lori M Gawron
- Division of Family Planning, Department of Obstetrics and Gynecology, University of Utah, 30N 1900E Rm 2B-200, Salt Lake City, UT, 84132, USA. .,VA Salt Lake City Health Care System, Salt Lake City, UT, USA.
| | - Tao He
- VA Salt Lake City Health Care System, Salt Lake City, UT, USA.,Division of Epidemiology Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - Lacey Lewis
- VA Salt Lake City Health Care System, Salt Lake City, UT, USA.,Division of Epidemiology Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - Hannah Fudin
- VA Salt Lake City Health Care System, Salt Lake City, UT, USA
| | - Lisa S Callegari
- VA Puget Sound Health Care System, Seattle, WA, USA.,Department of Obstetrics and Gynecology, University of Washington, Seattle, WA, USA
| | - David K Turok
- Division of Family Planning, Department of Obstetrics and Gynecology, University of Utah, 30N 1900E Rm 2B-200, Salt Lake City, UT, 84132, USA
| | - Vanessa Stevens
- VA Salt Lake City Health Care System, Salt Lake City, UT, USA.,Division of Epidemiology Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
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16
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Thorman A, Engle A, Brintz B, Simmons RG, Sanders JN, Gawron LM, Turok DK, Kaiser JE. Quantitative and qualitative impact of One Key Question on primary care providers' contraceptive counseling at routine preventive health visits. Contraception 2022; 109:73-79. [PMID: 35038448 PMCID: PMC9258909 DOI: 10.1016/j.contraception.2022.01.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 01/04/2022] [Accepted: 01/07/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVES One Key Question (OKQ) is a clinical screening tool to assess pregnancy desire in the next year. We aimed to 1) describe the effect of OKQ implementation on contraceptive counseling rates at preventive health visits and 2) evaluate primary care providers' perception of OKQ implementation on their contraceptive counseling practices. STUDY DESIGN We performed a quantitative retrospective chart review of preventive health visits at eight federally qualified health centers in Utah between 2014 and 2017. Implementation of OKQ included a brief training and inclusion of OKQ in the electronic medical record. Providers received OKQ training in August 2015 and re-training in March 2017. We assessed OKQ and contraceptive counseling documentation rates using interrupted-time-series analysis. We then conducted semi-structured interviews with providers and queried them about the impact of OKQ. We identified dominant themes using modified grounded theory to create an explanatory framework. RESULTS Abstracting 6634 charts yielded 9840 visits with 56 unique providers (51% physician assistant, 34% physician, 14% nurse practitioner). Interrupted-time-series analysis showed a documentation increase of OKQ in late 2015 (2.6%) and again in spring 2017 (9%), however rates remained low. Contraceptive counseling rates (39.7%) did not change after OKQ implementation. Charts with evidence of a current contraceptive method were less likely to have a OKQ response documented. Interviewees reported OKQ's algorithm did not alter their contraceptive counseling. CONCLUSIONS OKQ did not change documented rates of contraceptive counseling and uptake was low in quantitative and qualitative analyses. Our study suggests limited usefulness of OKQ in the primary care setting. IMPLICATIONS Implementation of the One Key Question tool through training and optional EHR field did not increase documented rates of contraceptive counseling in a large federally qualified health center or affect provider contraceptive counseling. Our study suggests limited usefulness of OKQ as a robust screening tool in this primary care setting.
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Affiliation(s)
- Alyssa Thorman
- University of Utah, School of Medicine, Salt Lake City, UT, United States
| | - Alyssa Engle
- University of Utah, School of Medicine, Salt Lake City, UT, United States
| | - Benjamin Brintz
- University of Utah, Study Design and Biostatistics Center, Salt Lake City, UT, United States
| | - Rebecca G Simmons
- University of Utah, Division of Family Planning, Salt Lake City, UT, United States
| | - Jessica N Sanders
- University of Utah, Division of Family Planning, Salt Lake City, UT, United States
| | - Lori M Gawron
- University of Utah, Division of Family Planning, Salt Lake City, UT, United States
| | - David K Turok
- University of Utah, Division of Family Planning, Salt Lake City, UT, United States
| | - Jennifer E Kaiser
- University of Utah, Division of Family Planning, Salt Lake City, UT, United States.
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Storck KE, Gawron LM, Sanders JN, Wiaderny N, Turok DK. “I just had to pay the money and be supportive”: A qualitative exploration of the male-partner role in contraceptive decision-making in Salt Lake City, Utah family planning clinics. Contraception 2022; 113:78-83. [DOI: 10.1016/j.contraception.2022.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 04/06/2022] [Accepted: 04/11/2022] [Indexed: 11/03/2022]
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18
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Kozlowski Z, Sanders JN, Panushka K, Myers K, Millar MM, Gawron LM. "It's a Vicious Cycle": A Mixed Methods Study of the Role of Family Planning in Housing Insecurity for Women. J Health Care Poor Underserved 2022; 33:104-119. [DOI: 10.1353/hpu.2022.0009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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19
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Kaiser JE, Galindo E, Sanders JN, Simmons RG, Gawron LM, Herrick JS, Brintz B, Turok DK. Determining the impact of the Zika pandemic on primary care providers' contraceptive counseling of non-pregnant patients in the US: a mixed methods study. BMC Health Serv Res 2021; 21:1215. [PMID: 34753479 PMCID: PMC8579600 DOI: 10.1186/s12913-021-07170-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 10/12/2021] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Global pandemics like Zika (ZIKV) factor into pregnancy planning and avoidance, yet little is known about how primary care providers (PCPs) incorporate public health guidance into contraceptive counseling. Study objectives include: 1) determining the impact of the ZIKV pandemic on contraceptive counseling changes; and 2) assessing PCP knowledge and practice regarding contraception, ZIKV, and CDC ZIKV guidelines. METHODS Study components included: (1) a retrospective review of electronic health records of non-pregnant, reproductive age women presenting for preventive health visits between 2014 and 2017 assessed using interrupted time series analyses (ITSA) to identify changes in documentation of ZIKV risk assessment and contraceptive counseling; and (2) a sequential, cross-sectional study with quantitative surveys and qualitative, semi-structured interviews of PCPs providing preventive care to non-pregnant patients at eight federally qualified health centers in Utah. We performed descriptive analyses on survey data and analyzed qualitative data for dominant themes using a modified Health Belief Model. RESULTS We conducted 6634 chart reviews yielding 9840 visits. The ITSA did not reveal changes in ZIKV risk assessment or contraceptive counseling. Twenty-two out of 40 (55%) eligible providers participated in the provider component. Participants averaged 69 and 81% correct on contraceptive and ZIKV knowledge questions, respectively. Sixty-five percent reported counseling consistent with CDC ZIKV guidelines. Qualitative analysis found providers unlikely to prioritize ZIKV risk assessment in contraceptive counseling for non-pregnant patients. CONCLUSIONS PCPs who care for non-pregnant women are knowledgeable about contraception and ZIKV; however, there was no change in ZIKV risk assessment or contraceptive counseling. This stresses the importance of developing strategies to improve guideline uptake.
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Affiliation(s)
- Jennifer E Kaiser
- University of Utah, Division of Family Planning, 50 North Medical Drive, Salt Lake City, UT, 84132, USA.
| | - Eduardo Galindo
- University of Utah, Division of Family Planning, 50 North Medical Drive, Salt Lake City, UT, 84132, USA
| | - Jessica N Sanders
- University of Utah, Division of Family Planning, 50 North Medical Drive, Salt Lake City, UT, 84132, USA
| | - Rebecca G Simmons
- University of Utah, Division of Family Planning, 50 North Medical Drive, Salt Lake City, UT, 84132, USA
| | - Lori M Gawron
- University of Utah, Division of Family Planning, 50 North Medical Drive, Salt Lake City, UT, 84132, USA
| | - Jennifer S Herrick
- University of Utah, Study Design and Biostatistics Center, 295 Chipeta Way, Salt Lake City, UT, 84122, USA
| | - Benjamin Brintz
- University of Utah, Study Design and Biostatistics Center, 295 Chipeta Way, Salt Lake City, UT, 84122, USA
| | - David K Turok
- University of Utah, Division of Family Planning, 50 North Medical Drive, Salt Lake City, UT, 84132, USA
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20
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Walhof KA, Gawron LM, Turok DK, Sanders JN. Long-Term Failure Rates of Interval Filshie Clips As a Method of Permanent Contraception. Womens Health Rep (New Rochelle) 2021; 2:279-284. [PMID: 34327509 PMCID: PMC8317595 DOI: 10.1089/whr.2021.0017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 06/15/2021] [Indexed: 06/13/2023]
Abstract
Background: In 1996, the U.S. Collaborative Review of Sterilization (CREST) reported permanent contraception failure rates by method, but did not include the Filshie clip. Subsequent research provides data for Filshie clip failure rates up to 24 months, but rigorously designed and executed studies examining failure rates beyond 2 years are lacking. Objectives: To describe non-Filshie and Filshie procedures, identify failures, and calculate 10-year pregnancy rates among patients who have undergone interval permanent contraception procedures with Filshie clips. Study Design: We performed chart review for patients who underwent interval permanent contraception procedures between 2000 and 2014 at our institution. We identified births after permanent contraception by utilizing both chart review and the Utah Population Database. We report results from life table analysis, with censoring at failure, 49 years of age, or last observed date of service. Results: In this cohort of 693 patients, surgeons most commonly used Filshie clips for interval permanent contraception (N = 547, 78.8%). We classified pregnancies after Filshie clip procedures as verified (n = 4) or self-reported (n = 3). We obtained 5 years of data for 411 patients (59.3% of all permanent contraception procedures), and more than 10 years of data for 257 patients (37.1%). We calculated a cumulative 5- and 10-year pregnancy rate to be the same, including both verified and self-reported pregnancies, of 9.8 (95% confidence interval [CI] 4.1-23.3)/1000 women using Filshie clips. The 10-year rate of verified pregnancy is 2.8 (95% CI 1.0-15.7)/1000 women. Conclusion: Overall, long-term failure of Filshie clip interval permanent contraception procedures is infrequent, with a 10-year cumulative probability of failure of 4.1-23.3/1000 procedures performed. Filshie clips compare favorably with other methods of permanent contraception included in the CREST study, where the 10-year cumulative probability of failure ranged from 7.5 to 36.5/1000 procedures performed.
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Affiliation(s)
- Kimberly A. Walhof
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah, USA
| | - Lori M. Gawron
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah, USA
| | - David K. Turok
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah, USA
| | - Jessica N. Sanders
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah, USA
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Gawron LM, Simonsen S, Millar MM, Lewis-Caporal J, Patel S, Simmons RG. Pregnancy Risk Screening and Counseling for Women Veterans: Piloting the One Key Question in the Veterans Healthcare Administration. South Med J 2021; 114:150-155. [PMID: 33655308 DOI: 10.14423/smj.0000000000001218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Women veterans have a high prevalence of comorbidities that increase the risk of adverse pregnancy outcomes. Screening for pregnancy desires in primary care provider (PCP) visits offers an opportunity to optimize preconception health. This pilot quality improvement initiative sought to assess Veterans Healthcare Administration provider preferences on One Key Question (OKQ) implementation, identification of veterans' reproductive needs, and the effect of training on documentation in a women's primary care clinic in Salt Lake City, Utah. METHODS We hosted OKQ training sessions for providers and staff, audio recorded group discussions on implementation barriers, and explored themes. Women veterans presenting for a PCP visit in July 2018 self-completed a paper OKQ screening tool. We calculated summary statistics on responses. We conducted a pre-post analysis, with respect to training sessions, to measure for changes in family planning documentation during PCP visits. RESULTS Nineteen providers and staff completed the training. They acknowledged the importance, but believed that the screening tool should be completed by veterans and not be provider prompted. Forty-two women veterans completed the screening tool: 21% desired pregnancy in the next year and 26% desired contraceptive information. Chart reviews found a nonsignificant increase in current contraceptive method documentation between periods (20% vs 37%; P = 0.08), a decline in documentation of reproductive goals (22% vs 3%; P = 0.02), and no significant change in counseling. CONCLUSIONS Veterans identify reproductive needs via the OKQ screening tool, but provider documentation did not reflect changes in care following training. Further study is necessary to develop an optimal, patient-centered tool and implementation plan to support women veterans in their reproductive goals.
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Affiliation(s)
- Lori M Gawron
- From the Department of Obstetrics and Gynecology, the College of Nursing, and the Department of Internal Medicine, Division of Epidemiology, University of Utah, Salt Lake City, the Salt Lake City Veterans Healthcare Administration, Salt Lake City, Utah
| | - Sara Simonsen
- From the Department of Obstetrics and Gynecology, the College of Nursing, and the Department of Internal Medicine, Division of Epidemiology, University of Utah, Salt Lake City, the Salt Lake City Veterans Healthcare Administration, Salt Lake City, Utah
| | - Morgan M Millar
- From the Department of Obstetrics and Gynecology, the College of Nursing, and the Department of Internal Medicine, Division of Epidemiology, University of Utah, Salt Lake City, the Salt Lake City Veterans Healthcare Administration, Salt Lake City, Utah
| | - Jessica Lewis-Caporal
- From the Department of Obstetrics and Gynecology, the College of Nursing, and the Department of Internal Medicine, Division of Epidemiology, University of Utah, Salt Lake City, the Salt Lake City Veterans Healthcare Administration, Salt Lake City, Utah
| | - Shardool Patel
- From the Department of Obstetrics and Gynecology, the College of Nursing, and the Department of Internal Medicine, Division of Epidemiology, University of Utah, Salt Lake City, the Salt Lake City Veterans Healthcare Administration, Salt Lake City, Utah
| | - Rebecca G Simmons
- From the Department of Obstetrics and Gynecology, the College of Nursing, and the Department of Internal Medicine, Division of Epidemiology, University of Utah, Salt Lake City, the Salt Lake City Veterans Healthcare Administration, Salt Lake City, Utah
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22
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Turok DK, Gero A, Simmons RG, Kaiser JE, Stoddard GJ, Sexsmith CD, Gawron LM, Sanders JN. Levonorgestrel vs. Copper Intrauterine Devices for Emergency Contraception. N Engl J Med 2021; 384:335-344. [PMID: 33503342 PMCID: PMC7983017 DOI: 10.1056/nejmoa2022141] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND In the United States, more intrauterine device (IUD) users select levonorgestrel IUDs than copper IUDs for long-term contraception. Currently, clinicians offer only copper IUDs for emergency contraception because data are lacking on the efficacy of the levonorgestrel IUD for this purpose. METHODS This randomized noninferiority trial, in which participants were unaware of the group assignments, was conducted at six clinics in Utah and included women who sought emergency contraception after at least one episode of unprotected intercourse within 5 days before presentation and agreed to placement of an IUD. We randomly assigned participants in a 1:1 ratio to receive a levonorgestrel 52-mg IUD or a copper T380A IUD. The primary outcome was a positive urine pregnancy test 1 month after IUD insertion. When a 1-month urine pregnancy test was unavailable, we used survey and health record data to determine pregnancy status. The prespecified noninferiority margin was 2.5 percentage points. RESULTS Among the 355 participants randomly assigned to receive levonorgestrel IUDs and 356 assigned to receive copper IUDs, 317 and 321, respectively, received the interventions and provided 1-month outcome data. Of these, 290 in the levonorgestrel group and 300 in the copper IUD group had a 1-month urine pregnancy test. In the modified intention-to-treat and per-protocol analyses, pregnancy rates were 1 in 317 (0.3%; 95% confidence interval [CI], 0.01 to 1.7) in the levonorgestrel group and 0 in 321 (0%; 95% CI, 0 to 1.1) in the copper IUD group; the between-group absolute difference in both analyses was 0.3 percentage points (95% CI, -0.9 to 1.8), consistent with the noninferiority of the levonorgestrel IUD to the copper IUD. Adverse events resulting in participants seeking medical care in the first month after IUD placement occurred in 5.2% of participants in the levonorgestrel IUD group and 4.9% of those in the copper IUD group. CONCLUSIONS The levonorgestrel IUD was noninferior to the copper IUD for emergency contraception. (Supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development and others; ClinicalTrials.gov number, NCT02175030.).
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Affiliation(s)
- David K Turok
- From the Division of Family Planning, Department of Obstetrics and Gynecology (D.K.T., A.G., R.G.S., J.E.K., C.D.S., L.M.G., J.N.S.), and the Division of Epidemiology, Department of Internal Medicine (G.J.S.), University of Utah, Salt Lake City
| | - Alexandra Gero
- From the Division of Family Planning, Department of Obstetrics and Gynecology (D.K.T., A.G., R.G.S., J.E.K., C.D.S., L.M.G., J.N.S.), and the Division of Epidemiology, Department of Internal Medicine (G.J.S.), University of Utah, Salt Lake City
| | - Rebecca G Simmons
- From the Division of Family Planning, Department of Obstetrics and Gynecology (D.K.T., A.G., R.G.S., J.E.K., C.D.S., L.M.G., J.N.S.), and the Division of Epidemiology, Department of Internal Medicine (G.J.S.), University of Utah, Salt Lake City
| | - Jennifer E Kaiser
- From the Division of Family Planning, Department of Obstetrics and Gynecology (D.K.T., A.G., R.G.S., J.E.K., C.D.S., L.M.G., J.N.S.), and the Division of Epidemiology, Department of Internal Medicine (G.J.S.), University of Utah, Salt Lake City
| | - Gregory J Stoddard
- From the Division of Family Planning, Department of Obstetrics and Gynecology (D.K.T., A.G., R.G.S., J.E.K., C.D.S., L.M.G., J.N.S.), and the Division of Epidemiology, Department of Internal Medicine (G.J.S.), University of Utah, Salt Lake City
| | - Corinne D Sexsmith
- From the Division of Family Planning, Department of Obstetrics and Gynecology (D.K.T., A.G., R.G.S., J.E.K., C.D.S., L.M.G., J.N.S.), and the Division of Epidemiology, Department of Internal Medicine (G.J.S.), University of Utah, Salt Lake City
| | - Lori M Gawron
- From the Division of Family Planning, Department of Obstetrics and Gynecology (D.K.T., A.G., R.G.S., J.E.K., C.D.S., L.M.G., J.N.S.), and the Division of Epidemiology, Department of Internal Medicine (G.J.S.), University of Utah, Salt Lake City
| | - Jessica N Sanders
- From the Division of Family Planning, Department of Obstetrics and Gynecology (D.K.T., A.G., R.G.S., J.E.K., C.D.S., L.M.G., J.N.S.), and the Division of Epidemiology, Department of Internal Medicine (G.J.S.), University of Utah, Salt Lake City
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Disney EA, Sanders JN, Turok DK, Gawron LM. Preconception Counseling, Contraceptive Counseling, and Long-Acting Reversible Contraception Use in Women with Type I Diabetes: A Retrospective Cohort Study. Womens Health Rep (New Rochelle) 2020; 1:334-340. [PMID: 33786497 PMCID: PMC7784811 DOI: 10.1089/whr.2020.0042] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 06/12/2020] [Indexed: 11/12/2022]
Abstract
Background: Reproductive-age women with type I diabetes require preconception counseling, contraceptive counseling, and access to long-acting reversible contraception (LARC) to better support peri-conception glycemic control and decrease rates of unplanned pregnancies and adverse pregnancy outcomes. Materials and Methods: This retrospective cohort study identified women (16-49 years old) with an ICD-9/ICD-10 code for type I diabetes and documented hemoglobin A1c (HbA1c) level in a tertiary referral center between January 1, 2010 and October 30, 2017. We abstracted 2 years of data centered on the time of the highest recorded HbA1c. We identified preconception counseling, contraceptive counseling, LARC use, provider type, and the presence of advanced vascular complications or disease >20 years duration. Multivariable logistic regression related disease severity and provider type to counseling and LARC documentation when controlling for patient age and race. Results: Among 541 women, only 5% received preconception counseling, 25% received contraceptive counseling, and 13% used LARC. Younger age and more visits were associated with documented preconception or contraceptive counseling (p < 0.01). Maternal fetal medicine specialists most frequently documented preconception counseling (16%, p = 0.01), whereas gynecologists most frequently documented contraceptive counseling (73%, p < 0.01). Contraceptive counseling was highly associated with LARC use (adjusted odds ratio 9.87, 95% confidence interval 5.09-19.12). Conclusions: Reproductive-age women with type I diabetes have infrequent documentation of preconception counseling and contraceptive counseling. Educating primary care providers and endocrinologists could avoid missed opportunities to improve pregnancy planning and outcomes.
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Affiliation(s)
- Elizabeth A. Disney
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah, USA
| | - Jessica N. Sanders
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah, USA
| | - David K. Turok
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah, USA
| | - Lori M. Gawron
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah, USA
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24
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Gawron LM, Gero A, Kushner KL, Turok DK, Sanders JN. Unprotected intercourse in the 2 weeks prior to quick-start initiation of an etonogestrel contraceptive implant with and without use of oral emergency contraception. Am J Obstet Gynecol 2020; 222:S891-S892. [PMID: 31809707 PMCID: PMC7219276 DOI: 10.1016/j.ajog.2019.11.1281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 10/07/2019] [Accepted: 11/05/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Lori M Gawron
- University of Utah, 30N 1900E, Room 2B-200, Salt Lake City, UT 84132.
| | - Alexandra Gero
- University of Utah, 30N 1900E, Room 2B-200, Salt Lake City, UT 84132
| | | | - David K Turok
- University of Utah, 30N 1900E, Room 2B-200, Salt Lake City, UT 84132
| | - Jessica N Sanders
- University of Utah, 30N 1900E, Room 2B-200, Salt Lake City, UT 84132
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25
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Gawron LM, Sanders JN, Sward K, Poursaid AE, Simmons R, Turok DK. Multi-morbidity and Highly Effective Contraception in Reproductive-Age Women in the US Intermountain West: a Retrospective Cohort Study. J Gen Intern Med 2020; 35:637-642. [PMID: 31701466 PMCID: PMC7080901 DOI: 10.1007/s11606-019-05425-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 04/20/2019] [Accepted: 08/23/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND Women with chronic health conditions benefit from reproductive planning and access to highly effective contraception. OBJECTIVE To determine the prevalence of and relationship between chronic health conditions and use of highly effective contraception among reproductive-age women. DESIGN Retrospective cohort study using electronic health records. PARTICIPANTS We identified all women 16-49 years who accessed care in the two largest health systems in the US Intermountain West between January 2010 and December 2014. MAIN MEASURES We employed administrative codes to identify highly effective contraception and flag chronic health conditions listed in the US Medical Eligibility Criteria for Contraceptive Use (US MEC) and known to increase risk of adverse pregnancy outcomes. We described use of highly effective contraception by demographics and chronic conditions. We used multinomial logistic regression to relate demographic and disease status to contraceptive use. KEY RESULTS Of 741,612 women assessed, 32.4% had at least one chronic health condition and 7.3% had two or more chronic conditions. Overall, 7.6% of women with a chronic health condition used highly effective contraception vs. 5.1% of women without a chronic condition. Women with chronic conditions were more likely to rely on public health insurance. The proportion of women using long-acting reversible contraception did not increase with chronic condition number (5.8% with 1 condition vs. 3.2% with 5 or more). In regression models adjusted for age, race, ethnicity, and payer, women with chronic conditions were more likely than those without chronic conditions to use highly effective contraception (aRR 1.4; 95% CI 1.4-1.5). Public insurance coverage was associated with both use of long-acting reversible contraception (aRR 2.2; 95% CI 2.1-2.3) and permanent contraception (aRR 2.9; 95% CI 2.7-3.1). CONCLUSIONS Nearly a third of reproductive-age women in a regional health system have one or more chronic health condition. Public insurance increases the likelihood that women with a chronic health condition use highly effective contraception.
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Affiliation(s)
- Lori M Gawron
- Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, UT, USA.
| | - Jessica N Sanders
- Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Katherine Sward
- College of Nursing, University of Utah, Salt Lake City, UT, USA.,Department of Biomedical Informatics, University of Utah, Salt Lake City, UT, USA
| | | | - Rebecca Simmons
- Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - David K Turok
- Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, UT, USA
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26
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Gawron LM, Simmons RG, Sanders JN, Myers K, Gundlapalli AV, Turok DK. The effect of a no-cost contraceptive initiative on method selection by women with housing insecurity. Contraception 2020; 101:205-209. [PMID: 31881219 PMCID: PMC7054141 DOI: 10.1016/j.contraception.2019.11.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 09/25/2019] [Accepted: 11/13/2019] [Indexed: 11/21/2022]
Abstract
OBJECTIVES To compare the sociodemographic characteristics of participants in a contraceptive initiative by housing security and determine the association between housing insecurity on contraceptive method selection before and after the removal of cost. STUDY DESIGN This cross-sectional assessment includes 4,327 reproductive-aged participants in the HER Salt Lake Contraceptive Initiative who sought new contraceptive services and reported housing status at enrollment. HER Salt Lake prospectively explored the impact of improved contraceptive access on socioeconomic outcomes in Salt Lake County (USA). For six months (September 2015-March 2016) we collected control data, which included clinic standard-of-care cost-sharing. The intervention started March 2016, and provided no-cost contraception services and unlimited opportunities for method switching over the subsequent three years. RESULTS There were 964 (22%) housing-insecure participants. Compared to those with stable housing, housing-insecure individuals more commonly identified as a sexual minority, received public assistance and lacked health insurance. Housing-insecure women preferentially selected long-acting reversible contraception during the control period (aOR 1.60; 95%CI 1.01-2.56), but method selection equalized across housing status during the intervention. CONCLUSIONS When cost is not a barrier, all women desire a comprehensive selection of contraceptive methods, regardless of housing security. Contraceptive clients in this vulnerable population need interventions which address access barriers to all methods to support reproductive planning. IMPLICATIONS Unintended pregnancy during housing insecurity may result in homelessness. This study found housing-insecure women desire access to all contraceptive methods, not just long acting reversible contraception. Integration of comprehensive family planning initiatives into efforts to address homelessness is essential to support this vulnerable population in their reproductive planning.
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Affiliation(s)
- Lori M Gawron
- Department of Obstetrics and Gynecology, University of Utah School of Medicine.
| | - Rebecca G Simmons
- Department of Obstetrics and Gynecology, University of Utah School of Medicine.
| | - Jessica N Sanders
- Department of Obstetrics and Gynecology, University of Utah School of Medicine.
| | - Kyl Myers
- Department of Obstetrics and Gynecology, University of Utah School of Medicine.
| | - Adi V Gundlapalli
- Department of Internal Medicine, University of Utah School of Medicine and VA Salt Lake City Health Care System.
| | - David K Turok
- Department of Obstetrics and Gynecology, University of Utah School of Medicine.
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Gawron LM, Pettey WB, Redd AM, Suo Y, Turok DK, Gundlapalli AV. Distance Matters: Geographic barriers to long acting reversible and permanent contraception for homeless women Veterans. J Soc Distress Homeless 2019; 28:139-148. [PMID: 31656390 PMCID: PMC6814171 DOI: 10.1080/10530789.2019.1619242] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Revised: 05/10/2019] [Accepted: 05/11/2019] [Indexed: 06/10/2023]
Abstract
Women Veterans who experience homelessness are at high risk of unintended pregnancy and adverse outcomes. Contraception could mitigate risks, yet access barriers exist across the Veterans Health Administration (VHA). We identified all US women Veterans, age 18-44y with evidence of homelessness in VHA administrative data between fiscal years 2002-2015, in order to document the geographic distribution of ever-homeless women Veterans in relation to VA Medical Centers (VAMCs) and assess geographic associations between long acting reversible contraceptives (LARC) or permanent contraception (PC) use. We calculated VAMC travel distance from last known ZIP Code. We used multivariate logistic regression models to explore contraceptive method associations. We included 41,722 ever-homeless women Veterans; 9.2% had LARC exposure and 7.5% PC. We found 29% of ever-homeless women Veterans resided >40miles from the nearest VAMC and increasing drive distance was negatively correlated with contraceptive exposure, especially for Veterans residing >100miles from a VAMC. Increasing distance to the nearest VAMC results in a geographic barrier to the most effective contraceptive options for women Veterans. The VHA is uniquely positioned to leverage its rural and homeless healthcare expertise to address geographic barriers and integrate comprehensive contraceptive services into established programs for high-risk Veterans.
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Affiliation(s)
- Lori M. Gawron
- Informatics, Decision Enhancement, and Analytic Sciences Center VA Salt Lake City Health Care System 500 N Foothill Dr. Salt Lake City, UT 84132 USA
- Departments of Obstetrics and Gynecology, University of Utah School of Medicine 30N 1900E Salt Lake City, UT 84132 USA
| | - Warren B.P. Pettey
- Informatics, Decision Enhancement, and Analytic Sciences Center VA Salt Lake City Health Care System 500 N Foothill Dr. Salt Lake City, UT 84132 USA
| | - Andrew M. Redd
- Informatics, Decision Enhancement, and Analytic Sciences Center VA Salt Lake City Health Care System 500 N Foothill Dr. Salt Lake City, UT 84132 USA
| | - Ying Suo
- Informatics, Decision Enhancement, and Analytic Sciences Center VA Salt Lake City Health Care System 500 N Foothill Dr. Salt Lake City, UT 84132 USA
| | - David K. Turok
- Departments of Obstetrics and Gynecology, University of Utah School of Medicine 30N 1900E Salt Lake City, UT 84132 USA
| | - Adi V. Gundlapalli
- Informatics, Decision Enhancement, and Analytic Sciences Center VA Salt Lake City Health Care System 500 N Foothill Dr. Salt Lake City, UT 84132 USA
- Department of Internal Medicine University of Utah School of Medicine 30N 1900E Salt Lake City, UT 84132 USA
- Department of Biomedical Informatics University of Utah School of Medicine 30N 1900E Salt Lake City, UT 84132 USA
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28
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Vricella LK, Gawron LM, Louis JM, Louis JM. Society for Maternal-Fetal Medicine (SMFM) Consult Series #48: Immediate postpartum long-acting reversible contraception for women at high risk for medical complications. Am J Obstet Gynecol 2019; 220:B2-B12. [PMID: 30738885 DOI: 10.1016/j.ajog.2019.02.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Reproductive planning is essential for all women and most important for those with complex health conditions or at high risk for complications. Pregnancy planning can allow these high-risk women the opportunity to receive preconception counseling, medication adjustment, and risk assessment related to health conditions that have a direct impact on maternal morbidity and mortality risk. Despite the need for pregnancy planning, medically complex women face barriers to contraceptive use, including systemic barriers, such as underinsurance for women at increased risk for complex medical conditions as well as low uptake of effective postpartum contraception. Providing contraceptive counseling and a full range of contraceptive options, including immediate postpartum long-acting reversible contraception (LARC), is a means of overcoming these barriers. The purpose of this document is to educate all providers, including maternal-fetal medicine subspecialists, about the benefits of postpartum contraception, and to advocate for widespread implementation of immediate postpartum LARC placement programs. The following are Society for Maternal-Fetal Medicine recommendations: we recommend that LARC be offered to women at highest risk for adverse health events as a result of a future pregnancy (GRADE 1B); we recommend that obstetric care providers discuss the availability of immediate postpartum LARC with all pregnant women during prenatal care and consult the U.S. Medical Eligibility Criteria for Contraceptive Use guidelines to determine methods most appropriate for specific medical conditions (GRADE 1C); we recommend that women considering immediate postpartum intrauterine device insertion be counseled that although expulsion rates are higher than with delayed insertion, the benefits appear to outweigh the risk of expulsion, as the long-term continuation rates are higher (GRADE 1C); we recommend that obstetric care providers wishing to utilize immediate postpartum LARC obtain training specific to the immediate postpartum period (BEST PRACTICE); for women who desire and are eligible for LARC, we recommend immediate postpartum placement after a high-risk pregnancy over delayed placement due to overall superior efficacy and cost-effectiveness (GRADE 1B); we recommend that women considering immediate postpartum LARC be encouraged to breastfeed, as current evidence suggests that these methods do not negatively influence lactation (GRADE 1B); for women who desire and are eligible for LARC, we suggest that early postpartum LARC placement be considered when immediate postpartum LARC placement is not feasible (GRADE 2C); and we recommend that contraceptive counseling programs be patient-centered and provided in a shared decision-making framework to avoid coercion (BEST PRACTICE).
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Affiliation(s)
| | | | | | - Judette M Louis
- Society for Maternal-Fetal Medicine, 409 12 St. SW, Washington, DC 20024, USA.
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Gawron LM, Mohanty AF, Kaiser JE, Gundlapalli AV. Impact of Deployment on Reproductive Health in U.S. Active-Duty Servicewomen and Veterans. Semin Reprod Med 2019; 36:361-370. [PMID: 31003251 DOI: 10.1055/s-0039-1678749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Reproductive-age women are a fast-growing component of active-duty military personnel who experience deployment and combat more frequently than previous service-era women Veterans. With the expansion of the number of women and their roles, the United States Departments of Defense and Veterans Affairs have prioritized development and integration of reproductive services into their health systems. Thus, understanding associations between deployments or combat exposures and short- or long-term adverse reproductive health outcomes is imperative for policy and programmatic development. Servicewomen and women Veterans may access reproductive services across civilian and military or Veteran systems and providers, increasing the need for awareness and communication regarding deployment experiences with a broad array of providers. An example is the high prevalence of military sexual trauma reported by women Veterans and the associated mental health diagnoses that may lead to a lifetime of high risk-coping behaviors that increase reproductive health risks, such as sexually transmitted infections, unintended pregnancies, and others. Care coordination models that integrate reproductive healthcare needs, especially during vulnerable times such as at the time of military separation and in the immediate postdeployment phase, may identify risk factors for early intervention with the potential to mitigate lifelong risks.
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Affiliation(s)
- Lori M Gawron
- Informatics, Decision Enhancement, and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, Utah.,Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, Utah
| | - April F Mohanty
- Informatics, Decision Enhancement, and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, Utah.,Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Jennifer E Kaiser
- Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, Utah
| | - Adi V Gundlapalli
- Informatics, Decision Enhancement, and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, Utah.,Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah.,Department of Biomedical Informatics, University of Utah School of Medicine, Salt Lake City, Utah
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30
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Sanders JN, Adkins DE, Kaur S, Storck K, Gawron LM, Turok DK. Bleeding, cramping, and satisfaction among new copper IUD users: A prospective study. PLoS One 2018; 13:e0199724. [PMID: 30403671 PMCID: PMC6221252 DOI: 10.1371/journal.pone.0199724] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Accepted: 10/23/2018] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE We assess change in bleeding, cramping, and IUD satisfaction among new copper (Cu) IUD users during the first six months of use, and evaluate the impact of bleeding and cramping on method satisfaction. METHODS We recruited 77 women ages 18-45 for this prospective longitudinal observational cohort study. Eligible women reported regular menses, had no exposure to hormonal contraception in the last three months, and desired a Cu IUD for contraception. We collected data prospectively for 180 days following IUD insertion. Monthly, participants reported bleeding scores using the validated pictorial blood loss assessment chart (PBAC), IUD satisfaction using a five-point Likert scale, and cramping using a six-level ordinal scale. We used multiple imputation to address nonrandom attrition. Structural equation models for count and ordered outcomes were used to model bleeding, cramping, and IUD satisfaction growth curves over the six monthly repeated assessments. RESULTS Bleeding significantly decreased (approximately 23%) over the course of the study from an estimated PBAC = 195 at one month post-insertion to PBAC = 151 at six months (t = -2.38, p<0.05). Additionally, IUD satisfaction improved over time (t = 2.65, p<0.01), increasing from between "Neutral" and "Satisfied" to "Satisfied" over the six month study. Cramping decreased notably over the six month study from between biweekly and weekly, to once or twice a month (t = -4.38, p<0.001). Finally, bleeding, but not cramping, was associated with IUD satisfaction across the study (t = -2.31, p<0.05) and at study end (t = -2.81, p<0.01). CONCLUSIONS New Cu IUD users reported decreasing bleeding and cramping, and increasing IUD satisfaction, over the first six months. Method satisfaction was negatively associated with bleeding.
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Affiliation(s)
- Jessica N. Sanders
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah, United States of America
| | - Daniel E. Adkins
- Department of Sociology, University of Utah, Salt Lake City, Utah, United States of America
- Department of Psychiatry, University of Utah, Salt Lake City, Utah, United States of America
- * E-mail:
| | - Simranvir Kaur
- School of Medicine, University of Utah, Salt Lake City, Utah, United States of America
| | - Kathryn Storck
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah, United States of America
| | - Lori M. Gawron
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah, United States of America
| | - David K. Turok
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah, United States of America
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31
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Turok DK, Simmons RG, Cappiello B, Gawron LM, Saviers-Steiger J, Sanders JN. Use of a novel suction cervical retractor for intrauterine device insertion: a pilot feasibility trial. BMJ Sex Reprod Health 2018; 45:bmjsrh-2017-200031. [PMID: 30396906 DOI: 10.1136/bmjsrh-2017-200031] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Revised: 09/25/2018] [Accepted: 10/02/2018] [Indexed: 06/08/2023]
Abstract
INTRODUCTION The Bioceptive suction cervical retractor (SCR) is a novel device that can replace the standard single-tooth tenaculum to place traction on the cervix. A feasibility trial was conducted on the device for intrauterine device (IUD) placement. METHODS Our three-stage feasibility process began with Stage 1, where the device was tested on in-vitro and ex-vivo samples. In Stage 2, 10 women received their IUD using the device. In Stage 3, a feasibility trial, we randomly assigned 25 consenting women to receive their IUD using either the Bioceptive SCR or the standard single-tooth tenaculum. In Stages 2 and 3, we collected pain scores using an electronically adapted 100-point visual analogue scale (VAS) at eight timepoints during and after the insertion procedure, as well as satisfaction and acceptability measures. The primary outcome was the pain score after attaching the SCR or tenaculum (VAS 3). Wilcoxon rank sum tests compared pain scores between devices. RESULTS In Stage 2, pain scores with the SCR were lower than historical controls with the single-tooth tenaculum. In Stage 3, the median VAS 3 pain scores were 31 and 57 for the intervention and control groups, respectively. The differences in pain scores were not statistically significant but the trend was to lower pain scores with the intervention. Reported patient satisfaction with the SCR device was 80% in Stage 2% and 90% in Stage 3. CONCLUSIONS The Bioceptive SCR has potential as an atraumatic alternative to standard cervical retractor devices for gynaecological procedures. These findings can guide point estimates for future clinical studies. TRIAL REGISTRATION NCT02283463.
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Affiliation(s)
- David K Turok
- Department of Obstetrics and Gynecology, University of Utah Hospital, Salt Lake City, Utah, USA
| | - Rebecca G Simmons
- Department of Obstetrics and Gynecology, University of Utah Hospital, Salt Lake City, Utah, USA
| | - Benjamin Cappiello
- Bioceptive, Inc, New Orleans BioInnovation Center, New Orleans, Louisiana, USA
| | - Lori M Gawron
- Department of Obstetrics and Gynecology, University of Utah Hospital, Salt Lake City, Utah, USA
| | - Jane Saviers-Steiger
- Department of Obstetrics and Gynecology, University of Utah Hospital, Salt Lake City, Utah, USA
| | - Jessica N Sanders
- Department of Obstetrics and Gynecology, University of Utah Hospital, Salt Lake City, Utah, USA
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Sanders JN, Higgins JA, Adkins DE, Stoddard GJ, Gawron LM, Turok DK. The Impact of Sexual Satisfaction, Functioning, and Perceived Contraceptive Effects on Sex Life on IUD and Implant Continuation at 1 Year. Womens Health Issues 2018; 28:401-407. [PMID: 30131221 PMCID: PMC6281294 DOI: 10.1016/j.whi.2018.06.003] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Revised: 06/20/2018] [Accepted: 06/20/2018] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Contraceptives improve women's lives and public health, but many women discontinue their contraceptive method owing to dissatisfaction. An underexamined aspect of contraceptive discontinuation is sexual acceptability, or how contraception affects sexual experiences. Investigators' aims were two-fold: 1) to document changes in multiple domains of women's sexual experiences with their intrauterine device (IUD) or contraceptive implant over time and 2) to examine whether these sexuality factors were associated with method continuation at 12 months. METHODS We enrolled 200 eligible family planning clients and collected data at baseline and at 1, 3, 6, and 12 months. Sexual acceptability measures included the Female Sexual Function Index-6, the New Sexual Satisfaction Scale, and participants' perceptions of whether their contraceptive method had had a neutral, positive, or negative effect on their sex life. Survival analysis and Cox regression with time-varying covariates related sexuality measures to method continuation over time while controlling for other relevant factors. RESULTS Among 193 women who received an IUD or implant, 20% selected the copper IUD, 46% the levonorgestrel IUD, and 34% the etonogestrel implant. Ten percent discontinued their method during the year. Although changes in Female Sexual Function Index-6 and New Sexual Satisfaction Scale scores were not associated with discontinuation, individuals who perceived that their method detracted from their sexual experience had significantly higher removal rates than those who reported no sexual changes or positive sexual changes (adjusted hazard ratio, 8.04; 95% CI, 1.53-42.24), even when controlling for method type, bleeding changes, and a variety of covariates and controls. CONCLUSIONS Although limited by the small sample of discontinuers, we found that women's perceptions of how their method affects their sex life were associated with contraceptive continuation over time. Sexual acceptability should receive more attention in both contraceptive research and counseling.
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Affiliation(s)
- Jessica N Sanders
- Department of Obstetrics and Gynecology, The University of Utah, Salt Lake City, Utah.
| | - Jenny A Higgins
- Department of Obstetrics and Gynecology and Department of Gender Studies, University of Wisconsin, Madison, Wisconsin
| | - Daniel E Adkins
- Department of Sociology and Department of Psychiatry, The University of Utah, Salt Lake City, Utah
| | - Greggory J Stoddard
- Department of Internal Medicine, The University of Utah, Salt Lake City, Utah
| | - Lori M Gawron
- Department of Obstetrics and Gynecology, The University of Utah, Salt Lake City, Utah
| | - David K Turok
- Department of Obstetrics and Gynecology, The University of Utah, Salt Lake City, Utah
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Sanders JN, Myers K, Gawron LM, Simmons RG, Turok DK. Contraceptive Method Use During the Community-Wide HER Salt Lake Contraceptive Initiative. Am J Public Health 2018; 108:550-556. [PMID: 29470119 PMCID: PMC5844407 DOI: 10.2105/ajph.2017.304299] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/15/2017] [Indexed: 12/31/2022]
Abstract
OBJECTIVES To describe a community-wide contraception initiative and assess changes in method use when cost and access barriers are removed in an environment with client-centered counseling. METHODS HER Salt Lake is a prospective cohort study occurring during three 6-month periods (September 2015 through March 2017) and nested in a quasiexperimental observational study. The sample was women aged 16 to 45 years receiving new contraceptive services at health centers in Salt Lake County, Utah. Following the control period, intervention 1 removed cost and ensured staffing and pharmacy stocking; intervention 2 introduced targeted electronic outreach. We used logistic regression and interrupted time series regression analyses to assess impact. RESULTS New contraceptive services were provided to 4107 clients in the control period, 3995 in intervention 1, and 3407 in intervention 2. The odds of getting an intrauterine device or implant increased 1.6 times (95% confidence interval [CI] = 1.5, 1.6) during intervention 1 and 2.5 times (95% CI = 2.2, 2.8) during intervention 2, relative to the control period. Time series analysis demonstrated that participating health centers placed an additional 59 intrauterine devices and implants on average per month (95% CI = 13, 105) after intervention 1. CONCLUSIONS Removing client cost and increasing clinic capacity was associated with shifts in contraceptive method mix in an environment with client-centered counseling; targeted electronic outreach further augmented these results.
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Affiliation(s)
- Jessica N Sanders
- All of the authors are with the Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City
| | - Kyl Myers
- All of the authors are with the Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City
| | - Lori M Gawron
- All of the authors are with the Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City
| | - Rebecca G Simmons
- All of the authors are with the Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City
| | - David K Turok
- All of the authors are with the Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City
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Gawron LM. Contraceptive Use in Women With Inflammatory Bowel Disease. Gastroenterol Hepatol (N Y) 2018; 14:176-179. [PMID: 29928162 PMCID: PMC6004041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Affiliation(s)
- Lori M Gawron
- Assistant Clinical Professor, Obstetrics and Gynecology University of Utah School of Medicine Salt Lake City, Utah
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Turok DK, Leeman L, Sanders JN, Thaxton L, Eggebroten JL, Yonke N, Bullock H, Singh R, Gawron LM, Espey E. Immediate postpartum levonorgestrel intrauterine device insertion and breast-feeding outcomes: a noninferiority randomized controlled trial. Am J Obstet Gynecol 2017; 217:665.e1-665.e8. [PMID: 28842126 PMCID: PMC6040814 DOI: 10.1016/j.ajog.2017.08.003] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Revised: 08/09/2017] [Accepted: 08/14/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND Immediate postpartum levonorgestrel intrauterine device insertion is increasing in frequency in the United States, but few studies have investigated the effect of early placement on breast-feeding outcomes. OBJECTIVE This study examined the effect of immediate vs delayed postpartum levonorgestrel intrauterine device insertion on breast-feeding outcomes. STUDY DESIGN We conducted this noninferiority randomized controlled trial at the University of Utah and the University of New Mexico Health Sciences Centers from February 2014 through March 2016. Eligible women were pregnant and planned to breast-feed, spoke English or Spanish, were aged 18-40 years, and desired a levonorgestrel intrauterine device. Enrolled women were randomized 1:1 to immediate postpartum insertion or delayed insertion at 4-12 weeks' postpartum. Prespecified exclusion criteria included delivery <37.0 weeks' gestational age, chorioamnionitis, postpartum hemorrhage, contraindications to levonorgestrel intrauterine device insertion, and medical complications of pregnancy that could affect breast-feeding. We conducted per-protocol analysis as the primary approach, as it is considered the standard for noninferiority studies; we also report the alternative intent-to-treat analysis. We powered the study for the primary outcome, breast-feeding continuation at 8 weeks, to detect a 15% noninferiority margin between groups, requiring 132 participants in each arm. The secondary study outcome, time to lactogenesis, used a validated measure, and was analyzed by survival analysis and log rank test. We followed up participants for ongoing data collection for 6 months. Only the data analysis team was blinded to the intervention. RESULTS We met the enrollment target with 319 participants, but lost 34 prior to randomization and excluded an additional 26 for medical complications prior to delivery. The final analytic sample included 132 in the immediate group and 127 in the delayed group. Report of any breast-feeding at 8 weeks in the immediate group (79%; 95% confidence interval, 70-86%) was noninferior to that of the delayed group (84%; 95% confidence interval, 76-91%). The 5% difference in breast-feeding continuation at 8 weeks between the groups fell within the noninferiority margin (95% confidence interval, -5.6 to 15%). Time to lactogenesis (mean ± SD) in the immediate group, 65.3 ± 25.7 hours, was noninferior to that of the delayed group, 63.6 ± 21.6 hours. The mean difference between groups was 1.7 hours (95% confidence interval, -4.8 to 8.2 hours), noninferior by log-rank test. A total of 24 intrauterine device expulsions occurred in the immediate group compared to 2 in the delayed group (19% vs 2%, P < .001), consistent with the known higher expulsion rate with immediate vs delayed postpartum intrauterine device insertion. No intrauterine device perforations occurred in either group. CONCLUSION Our results of noninferior breast-feeding outcomes between women with immediate and delayed postpartum levonorgestrel intrauterine device insertion suggest that immediate postpartum intrauterine device insertion is an acceptable option for women planning to breast-feed and use the levonorgestrel intrauterine device. Expulsion rates are higher with immediate postpartum levonorgestrel intrauterine device insertion compared to delayed insertion, but this disadvantage may be outweighed by the advantages of immediate initiation of contraception. Providers should offer immediate postpartum intrauterine device insertion to breast-feeding women planning to use the levonorgestrel intrauterine device.
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Affiliation(s)
- David K Turok
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT.
| | - Lawrence Leeman
- Department of Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque, NM; Department of Obstetrics and Gynecology, University of New Mexico School of Medicine, Albuquerque, NM
| | - Jessica N Sanders
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT
| | - Lauren Thaxton
- Department of Obstetrics and Gynecology, University of New Mexico School of Medicine, Albuquerque, NM
| | | | - Nicole Yonke
- Department of Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque, NM
| | - Holly Bullock
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT
| | - Rameet Singh
- Department of Obstetrics and Gynecology, University of New Mexico School of Medicine, Albuquerque, NM
| | - Lori M Gawron
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT
| | - Eve Espey
- Department of Obstetrics and Gynecology, University of New Mexico School of Medicine, Albuquerque, NM
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Gawron LM, Redd A, Suo Y, Pettey W, Turok DK, Gundlapalli AV. Long-acting Reversible Contraception Among Homeless Women Veterans With Chronic Health Conditions: A Retrospective Cohort Study. Med Care 2017; 55 Suppl 9 Suppl 2:S111-S120. [PMID: 28806374 PMCID: PMC5654542 DOI: 10.1097/mlr.0000000000000765] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND US women Veterans are at increased risk of homelessness and chronic health conditions associated with unintended pregnancy. Veterans Health Administration (VHA) provision of long-acting reversible contraception (LARC) can assist in healthy pregnancy planning. OBJECTIVES To evaluate perinatal risk factors and LARC exposure in ever-homeless women Veterans. RESEARCH DESIGN A retrospective cohort study of women Veterans using VHA administrative data from fiscal years 2002-2015. SUBJECTS We included 41,747 ever-homeless women Veterans age 18-44 years and 46,391 housed women Veterans matched by military service period. A subgroup of 7773 ever-homeless and 8674 matched housed women Veterans deployed in Iraq and Afghanistan [Operations Enduring Freedom/Iraqi Freedom/New Dawn (OEF/OIF/OND)] conflicts comprised a second analytic cohort. MEASURES Descriptive statistics compared demographic, military, health conditions, and LARC exposure in ever-homeless versus housed women Veterans. Multivariable logistic regression explored factors associated with LARC exposure in the OEF/OIF/OND subgroup. RESULTS All health conditions were significantly higher in ever-homeless versus housed Veterans: mental health disorder in 84.5% versus 48.7% (P<0.001), substance abuse in 35.8% versus 8.6% (P<0.001), and medical conditions in 74.7% versus 55.6% (P<0.001). LARC exposure among all VHA users was 9.3% in ever-homeless Veterans versus 5.4% in housed Veterans (P<0.001). LARC exposure in the OEF/OIF/OND cohort was 14.1% in ever-homeless Veterans versus 8.2% in housed Veterans (P<0.001). In the OEF/OIF/OND cohort, homelessness along Veterans with medical and mental health indicators were leading LARC exposure predictors. CONCLUSIONS The VHA is successfully engaging homeless women Veterans and providing LARC access. The prevalence of perinatal risk factors in ever-homeless women Veterans highlights a need for further programmatic enhancements to improve reproductive planning.
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Affiliation(s)
- Lori M. Gawron
- Informatics, Decision Enhancement, and Analytic Sciences Center, VA Salt Lake City Health Care System, Salt Lake City, UT
- Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, UT
| | - Andrew Redd
- Informatics, Decision Enhancement, and Analytic Sciences Center, VA Salt Lake City Health Care System, Salt Lake City, UT
| | - Ying Suo
- Informatics, Decision Enhancement, and Analytic Sciences Center, VA Salt Lake City Health Care System, Salt Lake City, UT
| | - Warren Pettey
- Informatics, Decision Enhancement, and Analytic Sciences Center, VA Salt Lake City Health Care System, Salt Lake City, UT
| | - David K. Turok
- Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, UT
| | - Adi V. Gundlapalli
- Informatics, Decision Enhancement, and Analytic Sciences Center, VA Salt Lake City Health Care System, Salt Lake City, UT
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT
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Sanders JN, Turok DK, Royer PA, Thompson IS, Gawron LM, Storck KE. One-year continuation of copper or levonorgestrel intrauterine devices initiated at the time of emergency contraception. Contraception 2017; 96:99-105. [PMID: 28596121 PMCID: PMC6040824 DOI: 10.1016/j.contraception.2017.05.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 05/24/2017] [Accepted: 05/26/2017] [Indexed: 01/15/2023]
Abstract
OBJECTIVE(S) This study compares 1-year intrauterine device (IUD) continuation among women presenting for emergency contraception (EC) and initiating the copper (Cu T380A) IUD or the levonorgestrel (LNG) 52 mg IUD plus 1.5 mg oral LNG. STUDY DESIGN This cohort study enrolled 188 women who presented at a single family planning clinic in Utah between June 2013 and September 2014 and selected either the Cu T380A IUD or LNG 52 mg IUD plus oral LNG for EC. Trained personnel followed participants by phone, text or e-mail for 12 months or until discontinuation occurred. We assessed reasons for discontinuation and used Cox proportional hazard models, Kaplan-Meier estimates and log-rank tests to assess differences in continuation rates between IUDs. RESULTS One hundred seventy-six women received IUDs; 66 (37%) chose the Cu T380A IUD and 110 (63%) chose the LNG 52 mg IUD plus oral LNG. At 1 year, we accounted for 147 (84%) participants, 33 (22%) had requested removals, 13 (9%) had an expulsion and declined reinsertion, 3 (2%) had a pregnancy with their IUD in place and 98 (67%) were still using their device. Continuation rates did not differ by IUD type; 60% of Cu T380A IUD users and 70% of LNG 52 mg IUD plus oral LNG users were still using their device at 12 months (adjusted hazard ratio 0.72, 95% confidence interval 0.40-1.3). CONCLUSION(S) Two-thirds of women who chose IUD placement at the EC clinical encounter continued use at 1 year. Women initiating Cu T380A IUD and LNG 52 mg IUD had similar 1-year continuation rates. These findings support same-day insertion of IUDs for women who are seeking EC and would like to use a highly effective reversible method going forward. IMPLICATIONS Providing IUD options for EC users presents an opportunity to increase availability of highly effective contraception.
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Affiliation(s)
- J N Sanders
- Department of Obstetrics and Gynecology, University of Utah, 30 North 1900 East, Room 2B200, Salt Lake City, UT 84132-2209, USA.
| | - D K Turok
- Department of Obstetrics and Gynecology, University of Utah, 30 North 1900 East, Room 2B200, Salt Lake City, UT 84132-2209, USA
| | - P A Royer
- Department of Obstetrics and Gynecology, University of Utah, 30 North 1900 East, Room 2B200, Salt Lake City, UT 84132-2209, USA
| | - I S Thompson
- Department of Obstetrics and Gynecology, University of Utah, 30 North 1900 East, Room 2B200, Salt Lake City, UT 84132-2209, USA
| | - L M Gawron
- Department of Obstetrics and Gynecology, University of Utah, 30 North 1900 East, Room 2B200, Salt Lake City, UT 84132-2209, USA
| | - K E Storck
- Department of Obstetrics and Gynecology, University of Utah, 30 North 1900 East, Room 2B200, Salt Lake City, UT 84132-2209, USA
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Sanders JN, Turok DK, Gawron LM, Law A, Wen L, Lynen R. Two-year continuation of intrauterine devices and contraceptive implants in a mixed-payer setting: a retrospective review. Am J Obstet Gynecol 2017; 216:590.e1-590.e8. [PMID: 28188772 PMCID: PMC6040817 DOI: 10.1016/j.ajog.2017.02.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Revised: 12/13/2016] [Accepted: 02/01/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND As the popularity of long-acting reversible contraception increases, so does the need for accurate data on method continuation in diverse clinical settings. We determined 2-year continuation rates for the levonorgestrel 52-mg intrauterine device, the copper T380A intra-uterine device, and the 68-mg etonogestrel contraceptive implant in an academic healthcare system with mixed-payer reimbursement. OBJECTIVE The purpose of this study was to examine the proportion and characteristics of women who continue intrauterine device and implant use to 2 years and to relate continuation to device type when controlling for patient characteristics. STUDY DESIGN This retrospective chart review assessed University of Utah Healthcare System patients who had an intrauterine device or contraceptive implant inserted between January 1, 2004, and December 31, 2012. We identified users and dates of insertions and removals by querying billing, medication, and procedural data in the Electronic Data Warehouse. Multivariable Poisson regression was conducted to estimate incidence risk ratios and to relate the probability of 2-year continuous use to device type. RESULTS Data on 8603 device insertions were obtained with the following distribution: levonorgestrel 52-mg intrauterine devices (6459; 75.1%), copper T380A intrauterine devices (1136; 13.2%), and 68-mg etonogestrel implant (1008; 11.7%). Two-year continuation rates were 77.8%, 73.1%, and 75.9%, respectively. There was no statistical difference in 2-year continuation between levonorgestrel 52-mg intrauterine device users (adjusted risk ratio, 1.1; 95% confidence interval, 1.0–1.1) and 68-mg etonogestrel implant users (adjusted risk ratio, 1.1; 95% confidence interval, 1.0–1.1) compared with copper device users, after we controlled for age, Hispanic ethnicity, payer type, and year of insertion. Older-age, self-pay, or public payer insurance (reference commercial payer) and Hispanic ethnicity were associated with 2-year continuation. CONCLUSION Three-quarters of women with an intrauterine device or implant continue using it for 2 years. In this cohort, the 2-year continuation rates were 77.8%, 73.1%, and 75.9% for the levonorgestrel 52-mg intrauterine device, copper T380A intrauterine device, and 68-mg etonogestrel implant, respectively.
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Affiliation(s)
- Jessica N Sanders
- University of Utah Department of Obstetrics and Gynecology, Salt Lake City, UT.
| | - David K Turok
- University of Utah Department of Obstetrics and Gynecology, Salt Lake City, UT
| | - Lori M Gawron
- University of Utah Department of Obstetrics and Gynecology, Salt Lake City, UT
| | - Amy Law
- Bayer HealthCare Pharmaceuticals, Whippany, NJ
| | - Lonnie Wen
- Bayer HealthCare Pharmaceuticals, Whippany, NJ
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Gawron LM, Watson K. Documenting moral agency: a qualitative analysis of abortion decision making for fetal indications. Contraception 2017; 95:175-180. [PMID: 27613571 PMCID: PMC6865283 DOI: 10.1016/j.contraception.2016.08.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Revised: 08/29/2016] [Accepted: 08/30/2016] [Indexed: 11/20/2022]
Abstract
OBJECTIVES We explored whether the decision-making process of women aborting a pregnancy for a fetal indication fit common medical ethical frameworks. STUDY DESIGN We applied three ethical frameworks (principlism, care ethics, and narrative ethics) in a secondary analysis of 30 qualitative interviews from women choosing 2nd trimester abortion for fetal indications. RESULTS All 30 women offered reasoning consistent with one or more ethical frameworks. Principlism themes included avoidance of personal suffering (autonomy), and sparing a child a poor quality of life and painful medical interventions (beneficence/non-maleficence). Care ethics reasoning included relational considerations of family needs and resources, and narrative ethics reasoning contextualized this experience into the patient's life story. CONCLUSIONS This population's universal application of commonly accepted medical ethical frameworks supports the position that patients choosing fetal indication abortions should be treated as moral decision-makers and given the same respect as patients making decisions about other medical procedures. IMPLICATIONS These findings suggest recent political efforts blocking abortion access should be reframed as attempts to undermine the moral decision-making of women.
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Affiliation(s)
- Lori M Gawron
- University of Utah School of Medicine, Department of Obstetrics and Gynecology, 30N 1900E Rm 2B-200, Salt Lake City, UT 84132.
| | - Katie Watson
- Northwestern University Feinberg School of Medicine, Department of Medical Humanities and Bioethics, Rubloff Building Suite 625, 750N Lakeshore Dr, Chicago, IL 60611.
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Gawron LM, Pettey WBP, Redd AM, Suo Y, Gundlapalli AV. Distance to Veterans Administration Medical Centers as a Barrier to Specialty Care for Homeless Women Veterans. Stud Health Technol Inform 2017; 238:112-115. [PMID: 28679900 PMCID: PMC6040819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Homeless women Veterans have a high prevalence of chronic mental and physical conditions that necessitate frequent healthcare visits, but travel burdens to specialty services may be overwhelming to navigate for this population, especially for those in rural settings. Access to specialty care is a key priority in the Veterans Health Administration (VHA) and understanding the geographic distribution and rural designation of this population in relation to medical centers (VAMC) can assist in care coordination. We identified 41,747 women Veterans age 18-44y with administrative evidence of homelessness in the VHA anytime during 2002-2015. We found 7% live in rural settings and 29% live >40miles from a VAMC. The mean travel distance for homeless women Veterans with a rural designation to a VAMC specialty center was 107 miles. Developing interventions to overcome this travel burden and engage vulnerable Veterans in necessary care can improve overall health outcomes for this high-risk population.
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Affiliation(s)
- Lori M Gawron
- VA Salt Lake City Health Care System & University of Utah, Salt Lake City, UT, USA
| | - Warren B P Pettey
- VA Salt Lake City Health Care System & University of Utah, Salt Lake City, UT, USA
| | - Andrew M Redd
- VA Salt Lake City Health Care System & University of Utah, Salt Lake City, UT, USA
| | - Ying Suo
- VA Salt Lake City Health Care System & University of Utah, Salt Lake City, UT, USA
| | - Adi V Gundlapalli
- VA Salt Lake City Health Care System & University of Utah, Salt Lake City, UT, USA
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Sanders JN, Gawron LM, Friedman S. Sexual satisfaction and inflammatory bowel diseases: an interdisciplinary clinical challenge. Am J Obstet Gynecol 2016; 215:58-62. [PMID: 26849974 DOI: 10.1016/j.ajog.2016.01.188] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Revised: 01/15/2016] [Accepted: 01/27/2016] [Indexed: 12/16/2022]
Abstract
Inflammatory bowel diseases (IBD), most commonly Crohn's disease and ulcerative colitis, have the highest incidence during the reproductive years. IBD and its treatments increase the risk of sexual dysfunction for both men and women with these diseases. Women with IBD often seek care from their gynecologist and may preferentially discuss sexual experiences with them over other providers. An understanding of IBD and its impact on sexual functioning and satisfaction will improve screening, evaluation, and management for these patients. Identifying interdisciplinary providers for referrals, such as pelvic floor physical therapists and health psychologists, is a key component to long-term improvements in sexual satisfaction for women with IBD.
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Affiliation(s)
- Jessica N Sanders
- Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, UT
| | - Lori M Gawron
- Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, UT.
| | - Sonia Friedman
- Division of Gastroenterology, Department of Medicine, Harvard Medical School, Brigham and Women's Hospital, Boston, MA
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Turok DK, Sanders JN, Thompson IS, Royer PA, Eggebroten J, Gawron LM. Preference for and efficacy of oral levonorgestrel for emergency contraception with concomitant placement of a levonorgestrel IUD: a prospective cohort study. Contraception 2016; 93:526-32. [PMID: 26944863 DOI: 10.1016/j.contraception.2016.01.009] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Revised: 01/19/2016] [Accepted: 01/19/2016] [Indexed: 12/30/2022]
Abstract
OBJECTIVES We assessed intrauterine device (IUD) preference among women presenting for emergency contraception (EC) and the probability of pregnancy among concurrent oral levonorgestrel (LNG) plus LNG 52 mg IUD EC users. METHODS We offered women presenting for EC at a single family planning clinic the CuT380A IUD (copper IUD) or oral LNG 1.5 mg plus the LNG 52 mg IUD. Two weeks after IUD insertion, participants reported the results of a self-administered home urine pregnancy test. The primary outcome, EC failure, was defined as pregnancies resulting from intercourse occurring within five days prior to IUD insertion. RESULTS One hundred eighty-eight women enrolled and provided information regarding their current menstrual cycle and recent unprotected intercourse. Sixty-seven (36%) chose the copper IUD and 121 (64%) chose oral LNG plus the LNG IUD. The probability of pregnancy two weeks after oral LNG plus LNG IUD EC use was 0.9% (95% CI 0.0-5.1%). The only positive pregnancy test after treatment occurred in a woman who received oral LNG plus the LNG IUD and who had reported multiple episodes of unprotected intercourse including an episode more than 5 days prior to treatment. CONCLUSIONS Study participants seeking EC who desired an IUD preferentially chose oral LNG 1.5 mg with the LNG 52 mg IUD over the copper IUD. Neither group had EC treatment failures. Including the option of oral LNG 1.5 mg with concomitant insertion of the LNG 52 mg IUD in EC counseling may increase the number of EC users who opt to initiate highly effective reversible contraception. IMPLICATIONS Consideration should be given to LNG IUD insertion with concomitant use of oral LNG 1.5 mg for EC. Use of this combination may increase the number of women initiating highly effective contraception at the time of their EC visit.
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Affiliation(s)
- David K Turok
- University of Utah, Department of Obstetrics and Gynecology, 30 North 1900 East, Room 2B200, Salt Lake City, UT 84132-2209.
| | - Jessica N Sanders
- University of Utah, Department of Obstetrics and Gynecology, 30 North 1900 East, Room 2B200, Salt Lake City, UT 84132-2209
| | - Ivana S Thompson
- University of Utah, Department of Obstetrics and Gynecology, 30 North 1900 East, Room 2B200, Salt Lake City, UT 84132-2209
| | - Pamela A Royer
- University of Utah, Department of Obstetrics and Gynecology, 30 North 1900 East, Room 2B200, Salt Lake City, UT 84132-2209
| | - Jennifer Eggebroten
- University of Utah, Department of Obstetrics and Gynecology, 30 North 1900 East, Room 2B200, Salt Lake City, UT 84132-2209
| | - Lori M Gawron
- University of Utah, Department of Obstetrics and Gynecology, 30 North 1900 East, Room 2B200, Salt Lake City, UT 84132-2209
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Abstract
Women with chronic medical conditions, such as inflammatory bowel diseases, are at increased risk for adverse pregnancy outcomes. Pregnancy outcomes for these conditions are best during stable disease remission. Unfortunately, women with inflammatory bowel disease are equally as likely as the general population to have unintended pregnancies. Patients look to their gastroenterologist for contraceptive counseling; however, the current standards for disease management do not prioritize this topic. Guidelines based on available evidence and expert opinion, such as the Centers for Disease Control U.S. Medical Eligibility Criteria for Contraceptive Use, exist to help practitioners provide safe and effective contraception to women with chronic medical conditions. If health care providers were to educate themselves and screen women with inflammatory bowel disease for risk of unintended pregnancy, there would be a reduction in the number of unintended pregnancies and subsequent adverse neonatal and maternal outcomes.
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Affiliation(s)
- Lori M. Gawron
- Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, Utah
| | - Jessica Sanders
- Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, Utah
| | | | - Ann D. Flynn
- Division of Gastroenterology and Nutrition, Department of Medicine, University of Utah School of Medicine, Salt Lake City, Utah
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Gawron LM, Turok DK. Pills on the World Wide Web: reducing barriers through technology. Am J Obstet Gynecol 2015; 213:500.e1-4. [PMID: 26071918 DOI: 10.1016/j.ajog.2015.06.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Revised: 05/30/2015] [Accepted: 06/02/2015] [Indexed: 11/26/2022]
Abstract
Oral contraceptive pills are safe, effective, and available without a prescription in most countries. Despite support from the American Congress of Obstetricians and Gynecologists to provide oral contraceptives as an over-the-counter medication, US women are still required to have a prescription to obtain them. Use of online applications and the Internet has made most things easier to obtain in our society and this includes contraceptive methods. Several online ventures are now underway to enable US women to obtain oral contraceptives without visiting a medical provider's office. Women's health care professionals should encourage these novel approaches, as they will improve contraceptive access. As US women experiment with innovative health care models, providers will need to lead, follow, or be left behind.
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Gawron LM, Goldberger AR, Gawron AJ, Hammond C, Keefer L. Disease-related pregnancy concerns and reproductive planning in women with inflammatory bowel diseases. ACTA ACUST UNITED AC 2015; 41:272-7. [PMID: 25902816 DOI: 10.1136/jfprhc-2014-101000] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Accepted: 03/19/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Women with inflammatory bowel diseases (IBD) endorse disease-related pregnancy concerns that influence parity. Improvements in IBD management have potentially altered reproductive planning. Additionally, the proportion of American women who choose not to have children is increasing. AIM To explore the effect of disease-related pregnancy concerns on parity and reproductive planning in a subset of women with IBD. DESIGN AND SETTING Cross-sectional qualitative phone survey in an academic gastroenterology practice. METHODS Questions included demographics, medical and reproductive history, future pregnancy plans, and if IBD affected pregnancy decision-making. Qualitative data were coded and frequencies and proportions calculated. RESULTS The 129 female participants (31% response rate) were predominately white (85%), had at least some college education (97%) and a mean age of 34.3 years [standard deviation 6.2]. Some 60% had Crohn's disease and 30% had undergone IBD-related surgery. Half were nulliparae, 53% reported IBD-related pregnancy concerns and 57% desired future pregnancy. Women who desired a future pregnancy and had IBD-related concerns had higher parity than those without concerns (p=0.02). Women desiring a future pregnancy and those with Crohn's disease had increased IBD-related concerns. Only four (3.1%) women identified IBD-related concerns that led to a smaller family size than desired. CONCLUSIONS IBD-related concerns appear to be less likely to affect a woman's planned family size than previously reported. Concern about adverse pregnancy outcomes is more common in women with Crohn's disease and those desiring future pregnancy, suggesting a need for targeted counselling to moderate risk perception.
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Affiliation(s)
- Lori M Gawron
- Assistant Professor, Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT, USA
| | - Adina R Goldberger
- Medical Student, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Andrew J Gawron
- Assistant Professor, Division of Gastroenterology, University of Utah, Salt Lake City, UT, USA
| | - Cassing Hammond
- Associate Professor, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Laurie Keefer
- Associate Professor, Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Gawron LM, Gawron AJ, Kasper A, Hammond C, Keefer L. Contraceptive method selection by women with inflammatory bowel diseases: a cross-sectional survey. Contraception 2014; 89:419-25. [PMID: 24486008 DOI: 10.1016/j.contraception.2013.12.016] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2013] [Revised: 12/22/2013] [Accepted: 12/24/2013] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Women with inflammatory bowel diseases (IBDs) utilize contraception at a lower rate than the general population. We sought to identify factors associated with contraceptive use and selection of more effective methods in IBD patients at risk for unintended pregnancy. STUDY DESIGN An online survey was distributed to women with IBD in January 2013. Contraceptive methods were categorized by effectiveness and associations with use explored by demographics, disease characteristics and reproductive goals. RESULTS A total of 162 respondents were analyzed: 62% had Crohn's disease and 38% ulcerative colitis. Mean age was 31 (range 20-45), 97% identified as White, and 53% were nulliparas. Seventy-four percent were currently using IBD medications. A quarter of participants (23%) used no contraception, 17% used highly effective methods, 41% used short-term hormonal methods, and 19% chose barrier/behavioral methods. Prior IBD-related surgery, biologic therapy use and low education attainment were associated with no contraception use. Of contraceptive users, age, parity, insurance status, IBD surgery and prior immunomodulator use were associated with highly effective method selection. CONCLUSIONS A quarter of women with IBD at risk for pregnancy in this study population reported no contraceptive method use. Higher levels of IBD activity influence contraceptive use and method selection, which could guide future patient and provider educational interventions. IMPLICATIONS Pregnancy planning is important for women with inflammatory bowel diseases to avoid adverse outcomes in a disease-poor state. Use of contraception assists in avoidance of unintended pregnancy. IBD characteristics are targets for educational interventions to improve uptake of highly effective contraceptive methods.
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Affiliation(s)
- Lori M Gawron
- Department of Obstetrics and Gynecology, Section of Family Planning, Northwestern University, Chicago, IL, USA.
| | - Andrew J Gawron
- Division of Hepatology and Gastroenterology, Northwestern University, Chicago, IL, USA
| | | | - Cassing Hammond
- Department of Obstetrics and Gynecology, Section of Family Planning, Northwestern University, Chicago, IL, USA
| | - Laurie Keefer
- Division of Hepatology and Gastroenterology, Northwestern University, Chicago, IL, USA
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Gawron LM, Hammond C, Keefer L. Documentation of reproductive health counseling and contraception in women with inflammatory bowel diseases. Patient Educ Couns 2014; 94:134-7. [PMID: 24126091 PMCID: PMC3985491 DOI: 10.1016/j.pec.2013.09.013] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2013] [Revised: 09/06/2013] [Accepted: 09/15/2013] [Indexed: 06/02/2023]
Abstract
OBJECTIVE Inflammatory bowel diseases (IBD) are commonly diagnosed during women's reproductive years. Counseling is important to avoid unintended pregnancy in a disease-poor state. We sought to determine reproductive counseling documentation by gastroenterologists in women with IBD. METHODS An electronic query identified women, age 18-45, with IBD in an academic gastroenterology practice from 2010 to 2012. A random sample (15%) chart review determined contraception documentation and content/frequency of reproductive counseling. RESULTS 100 patients were analyzed. Median age was 35 (range 19-45), 53% were married, and 69% had Crohn's disease. Median time since IBD diagnosis was 9 years (range 1-32) with a 5 visit median (range 1-45) over 31 months (range 1-105). A contraceptive method was identified in 24% of all patients. Nineteen patients (19%) had documentation of reproductive counseling. Only 1/100 patients had a specific reference to using contraception to avoid pregnancy. The remaining counseling included (1) medication effects on pregnancy, (2) disease control before pregnancy, or (3) mode of delivery planning. CONCLUSIONS Outside of listing contraception as a "current medication", documentation of reproductive counseling at gastroenterology visits for IBD is sparse. PRACTICE IMPLICATIONS In light of the importance of reproductive planning for women with IBD, future research on incentives and barriers to counseling is warranted.
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Affiliation(s)
- Lori M Gawron
- Department of Obstetrics and Gynecology, Northwestern University, Chicago, USA.
| | - Cassing Hammond
- Department of Obstetrics and Gynecology, Northwestern University, Chicago, USA
| | - Laurie Keefer
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, USA
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Gawron LM, Hammond C, Ernst LM. Perinatal pathologic examination of nonintact, second-trimester fetal demise specimens: the value of standardization. Arch Pathol Lab Med 2013; 137:1083-7. [PMID: 23899064 DOI: 10.5858/arpa.2012-0010-oa] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
CONTEXT Management of second-trimester intrauterine fetal demise via dilation and evacuation results in nonintact specimens for pathologic examination. Surgical pathology examination is often mandated; however, evidence on expected findings and specimen evaluation guidelines are lacking. OBJECTIVES To assess pathologic findings of nonintact, second-trimester fetal demise specimens, through comparison of anatomic abnormalities identified on standardized perinatal examination to individualized general pathology examinations. DESIGN Single institution, retrospective chart review of 14- to 24-week gestational size fetal demise cases was conducted from May 2006 to October 2010. Suspected abnormalities, chromosomal and pathologic diagnoses were collected. A general surgical pathology examination occurred between May 2006 and October 2008, while a perinatal pathologist examined specimens between October 2008 and October 2010. Statistical analysis consisted of t tests and χ(2) tests by Stata/SE 12.1. RESULTS One hundred eighteen specimens were included and mean gestational size was 16.0 weeks (standard deviation, 1.6 weeks). Perinatal pathologic evaluation diagnosed significantly more abnormalities than did general pathologic examination (77.3% [34 of 44] versus 9.5% [7 of 75], P < .001). Forty-eight abnormalities were identified: 77.0% (n = 37) were placental and 23.0% (n = 11) were fetal. Chromosomal analysis was done on 73.7% (n = 87 of 118) with 12.6% (n = 11 of 87) showing abnormalities. Among aneuploid specimens, the perinatal pathologist confirmed abnormalities in 66.7% (n = 4 of 6) of cases while general pathologists confirmed abnormalities in 0% (n = 0 of 5) (P = .02). CONCLUSIONS Systematic surgical pathology examination of nonintact, second-trimester fetal demise specimens yields increased information on fetal or placental abnormalities, which may be clinically useful. Institutions with high-risk obstetrical practices and dilation and evacuation providers should consider integrating a standardized perinatal checklist into educational and practice guidelines.
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Affiliation(s)
- Lori M Gawron
- Section of Family Planning and Contraception, Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois 60611, USA.
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Gawron LM, Cameron KA, Phisuthikul A, Simon MA. An exploration of women's reasons for termination timing in the setting of fetal abnormalities. Contraception 2012; 88:109-15. [PMID: 23352798 DOI: 10.1016/j.contraception.2012.12.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2012] [Revised: 11/14/2012] [Accepted: 12/06/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND Over 3% of pregnancies are complicated by a fetal abnormality, of which, approximately 80% are terminated. Despite early screening options, women often present at the cusp of legal limits for termination. STUDY DESIGN A qualitative study was conducted with women terminating pregnancies for fetal abnormalities. Semi-structured interviews explored reasons for termination timing. Analysis utilized latent content and constant comparative methods. RESULTS Of 30 participants between 13+4 and 23+5 weeks gestation, their median age was 35 years, 73.3% were white, 70% were religiously affiliated, and 60% had children. The median time from abnormality identification until termination was 16.5 days (range 2-73). The major themes for termination timing included (1) an abrupt shift in "low-risk" pregnancy perception; (2) challenging medical interactions; (3) an emotional decision-making process; and (4) termination access barriers. CONCLUSIONS Timing of termination for fetal abnormalities is attributable to multiple issues. Future research should identify optimal prenatal counseling strategies, address systemic barriers, and identify patient decision-making resources.
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Affiliation(s)
- Lori M Gawron
- Section of Family Planning and Contraception, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA.
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