1
|
Hoffman EA, Kaufman J, Koelper NC, Sonalkar S, Roe AH. Outcomes After Induction of Labor Compared With Dilation and Evacuation for the Management of Rupture of Membranes in the Second Trimester. Obstet Gynecol 2024; 143:550-553. [PMID: 38262065 DOI: 10.1097/aog.0000000000005515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 10/12/2023] [Indexed: 01/25/2024]
Abstract
Previable and periviable rupture of membranes is associated with significant morbidity for the pregnant patient. For those who have a choice of options and undergo active management, it is not known how the risks of induction of labor compare with those for dilation and evacuation (D&E). We performed a retrospective cohort study of patients with rupture of membranes between 14 0/7 and 23 6/7 weeks of gestation who opted for active management. Adverse events (52.2% vs 16.9%, P <.01) and time to uterine evacuation greater than 24 hours (26.7% vs 9.6%, P =.01) were more common among patients undergoing induction of labor. In a multivariable regression, induction of labor was an independent risk factor for complications (odds ratio 5.70, 95% CI, 2.35-13.82) compared with D&E. Severe complications were rare across both groups (4.4% for patients undergoing induction vs 2.6% for D&E, P =.63). Given the differing risks by termination method, access to D&E is an important treatment option for this patient population.
Collapse
Affiliation(s)
- Elizabeth A Hoffman
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | | | | | | |
Collapse
|
2
|
Chesnokova AE, Nagendra D, Dixit E, McAllister A, Schachter A, Schreiber CA, Roe AH, Sonalkar S. Trust in provider and stigma during second-trimester abortion. Sex Reprod Healthc 2024; 39:100932. [PMID: 38061314 DOI: 10.1016/j.srhc.2023.100932] [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: 03/03/2023] [Revised: 10/31/2023] [Accepted: 11/23/2023] [Indexed: 03/16/2024]
Abstract
OBJECTIVE To determine whether trust in the provider and sociodemographics are associated with individual-level abortion stigma. METHODS We performed a cross sectional and exploratory study design using secondary analysis of a randomized trial that enrolled participants undergoing second trimester abortion. We collected baseline survey data from 70 trial participants to assess stigma (Individual Level of Abortion Stigma scale, ILAS; range 0-4), trust in provider (Trust in Physician scale; range 1-5), anxiety, depression, and sociodemographics. We performed multiple linear regression, for which ILAS score was the outcome of interest. Univariate associations were used to inform the regression model. RESULTS The mean abortion stigma score was at the low end of the ILAS at 1.21 (range 0.2-2.8, SD 0.66). Age, race, income, BMI, parity, gestational age at time of abortion, and reasons for ending the pregnancy were not significantly associated with the ILAS score. Higher trust in provider scores were (m 4.0, SD 0.49) and inversely related to the ILAS score, even after adjustment for confounders (β -0.02, CI -0.03 to -0.004, p = 0.013). Screening positive for anxiety or depression was associated with a higher ILAS score ((β 0.48, CI 0.10, 0.90, p = 0.015); (β = 0.27 CI -0.097, 0.643)), while cohabitation was associated with lower ILAS score (β -0.44, CI -0.82 to -0.57, p = 0.025). CONCLUSIONS Trust in an abortion provider, anxiety, depression, and cohabitation are associated with abortion stigma among people seeking second trimester abortion care. Interventions that improve trust in a provider may be an area of focus for addressing abortion stigma. Future research should confirm these findings in larger populations and across diverse locations and demographics and to conduct qualitative research to understand what patients perceive as trust-promoting behaviors and words during abortion encounters.
Collapse
Affiliation(s)
- Arina E Chesnokova
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd., Philadelphia, PA 19104, USA
| | - Divyah Nagendra
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd., Philadelphia, PA 19104, USA
| | - Eshani Dixit
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd., Philadelphia, PA 19104, USA; Rutgers Robert Wood Johnson Medical School, 675 Hoes Lane West, Piscataway, NJ 08854, USA.
| | - Arden McAllister
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd., Philadelphia, PA 19104, USA
| | - Allison Schachter
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd., Philadelphia, PA 19104, USA
| | - Courtney A Schreiber
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd., Philadelphia, PA 19104, USA
| | - Andrea H Roe
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd., Philadelphia, PA 19104, USA
| | - Sarita Sonalkar
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd., Philadelphia, PA 19104, USA
| |
Collapse
|
3
|
Anand P, Bravo L, Gutman S, McAllister A, Keddem S, Sonalkar S. "I Wasn't Expecting That Question": Responses to Requests for Abortion Referral at College Student Health Centers. Womens Health Issues 2024:S1049-3867(23)00214-1. [PMID: 38246793 DOI: 10.1016/j.whi.2023.12.003] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 11/28/2023] [Accepted: 12/11/2023] [Indexed: 01/23/2024]
Abstract
BACKGROUND Women 18-24 years of age have the highest proportion of unintended pregnancies of any age group, and thus represent a significant population in need of abortion services. Prior research indicated that only half of college student health centers provide appropriate abortion referrals. Our objective was to better understand the referral experience and barriers to abortion referral at college student health centers. PROCEDURES We conducted a "secret caller" study at all 4-year colleges in Pennsylvania between June 2017 and April 2018, using a structured script requesting abortion referral. Calls were transcribed, coded using an iteratively developed codebook, and analyzed for themes related to barriers and facilitators of abortion referral. MAIN FINDINGS A total of 202 completed transcripts were reviewed. Themes that emerged were knowledge, experience, and comfort with abortion referral; support, empathy, and reassurance; coercion; misleading language; questioning the caller's autonomy; and institutional policy against referral. Most staff lacked knowledge and comfort with abortion referral. Although some staff members made supportive statements toward the caller, others used coercive language to try to dissuade the caller from an abortion. Many staff cited religious institutional policies against abortion referral and expressed a range of feelings about such policies. CONCLUSIONS Abortion referrals at student health centers lack consistency. Staff members frequently did not have the knowledge needed to provide appropriate abortion referrals, used coercive language in responding to requests for referrals, and perpetuated abortion stigma. Some health staff used coercive or evasive language that further stigmatized the caller's request for an abortion referral. College health centers should improve training and resources around abortion referral to ensure they are delivering appropriate, high-quality care.
Collapse
Affiliation(s)
- Priyanka Anand
- Department of Medicine, University of Washington, School of Medicine, Seattle, Washington
| | - Licia Bravo
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sarah Gutman
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Arden McAllister
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Shimrit Keddem
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sarita Sonalkar
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania
| |
Collapse
|
4
|
Flynn AN, McAllister A, Kete C, Koelper NC, Gallop RJ, Schreiber CA, Schapira MM, Sonalkar S. Evaluation of a decision aid for early pregnancy loss: A pilot randomized controlled trial in Philadelphia, Pennsylvania. Contraception 2023; 125:110077. [PMID: 37270163 DOI: 10.1016/j.contraception.2023.110077] [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: 12/22/2022] [Revised: 05/17/2023] [Accepted: 05/18/2023] [Indexed: 06/05/2023]
Abstract
OBJECTIVES To evaluate the effect of a decision aid on decisional conflict scale in patients choosing management for early pregnancy loss. STUDY DESIGN We conducted a pilot randomized control trial to assess the effect of the Healthwise patient decision aid on decisional conflict scale in patients with early pregnancy loss as compared with a control website. Patients 18years and older were eligible if they had an early pregnancy loss between 5 and 12 completed weeks of gestation. Participants completed surveys at baseline, poststudy intervention, after consultation, and 1week postconsultation. Surveys assessed participant scores on the decisional conflict scale (scale 0-100), knowledge, assessment of shared decision-making, satisfaction, and decision regret. Our primary outcome was the poststudy-intervention decisional conflict scale score. RESULTS From July 2020 through March 2021 we randomized 60 participants. After the intervention, the median decisional conflict scale score for the control group was 10 [0-30] and 0 [0-20] for the intervention group (p = 0.17). When assessing the decisional conflict scale subscales postintervention, the informed subscale for the control group was 16.7 [0-33.3] as opposed to 0 [0] for the patient decision aid group (p = 0.003). Knowledge remained significantly higher in the experimental arm from the postintervention to the 1-week follow-up. We found no differences between groups when assessing our other metrics. CONCLUSIONS Use of a validated decision aid did not result in statistically significant differences in the total decisional conflict scale scores as compared with the control. Participants allocated to the intervention were more informed postintervention and had consistently higher knowledge scores. IMPLICATIONS Use of a validated decision aid prior to early pregnancy loss management consultation did not affect overall decisional conflict but resulted in improved knowledge.
Collapse
Affiliation(s)
- Anne N Flynn
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States.
| | - Arden McAllister
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Corinne Kete
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Nathanael C Koelper
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Robert J Gallop
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Courtney A Schreiber
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Marilyn M Schapira
- Department of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Sarita Sonalkar
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| |
Collapse
|
5
|
Flynn AN, Koelper NC, Sonalkar S. Telephone-Based Intervention to Improve Family Planning Care in Pregnancies of Unknown Location: Retrospective Pre-Post Study. J Med Internet Res 2023; 25:e42559. [PMID: 37639302 PMCID: PMC10495846 DOI: 10.2196/42559] [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: 09/08/2022] [Revised: 06/22/2023] [Accepted: 07/30/2023] [Indexed: 08/29/2023] Open
Abstract
BACKGROUND Patients followed for a pregnancy of unknown location are generally followed by a team of clinicians through telephone calls, and their contraceptive needs at the time of pregnancy resolution may not be addressed. OBJECTIVE This study aimed to assess contraceptive counseling and contraceptive uptake before and after a telephone-based intervention. METHODS This was a retrospective pre-post study assessing pregnancy intendedness in patients with a pregnancy of unknown location and the proportion of patients who received contraceptive counseling and a contraceptive prescription before and after the initiation of a telephone-based intervention. We reviewed medical records 1 year before and 1 year after implementation of our intervention for demographic characteristics, pregnancy intendedness, pregnancy outcome, contraceptive counseling documentation, receipt of contraception, and repeat pregnancy within 6 months. We assessed the effects of an implementation strategy to address family planning needs once pregnancy was resolved by comparing the proportions of patients who were counseled and received contraception before and after our intervention was implemented. We performed logistic regression to identify associations between covariates and the outcomes of contraceptive counseling documentation and receipt of contraception. RESULTS Of the 220 patients in the combined cohort, the majority were Black (161/220, 73%) and ultimately had a resolved pregnancy of unknown location (162/220, 74%), and the proportion of pregnancies documented as unintended was 60% (132/220). Before our intervention, 27 of 100 (27%) patients received contraceptive counseling, compared with 94 of 120 (78%) patients after the intervention (odds ratio [OR] 9.77, 95% CI 5.26-18.16). Before the intervention, 17 of 90 (19%) patients who did not desire repeat pregnancy received contraception, compared with 32 of 86 (37%) patients after the intervention (OR 2.54, 95% CI 1.28-5.05). Our postintervention cohort had an increased odds of receiving contraceptive counseling (OR 9.77, 95% CI 5.26-18.16) and of receiving a contraceptive prescription (OR 2.54, 95% CI 1.28-5.05) compared with our preintervention cohort. CONCLUSIONS We found that over half of patients with a pregnancy of unknown location have an unintended pregnancy, and standardization of care through a telephone-based intervention improves contraceptive counseling and prescribing in patients with a resolved pregnancy of unknown location. This intervention could be used at any institution that follows patients with a pregnancy of unknown location remotely to improve care.
Collapse
Affiliation(s)
- Anne Nichols Flynn
- University of California, Davis, Sacramento, CA, United States
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA, United States
| | - Nathanael C Koelper
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA, United States
| | - Sarita Sonalkar
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA, United States
| |
Collapse
|
6
|
Sonalkar S, Kete C, McAllister A, Afreen R, Kaufman J, Short W, Keddem S. Perceptions of HIV risk screening strategies among patients seeking abortion, contraception, and pregnancy loss management in the United States. Contraception 2023; 124:110063. [PMID: 37210025 DOI: 10.1016/j.contraception.2023.110063] [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: 08/11/2022] [Revised: 05/09/2023] [Accepted: 05/12/2023] [Indexed: 05/22/2023]
Abstract
OBJECTIVES Women make up nearly a fifth of new human immunodeficiency virus (HIV) infections yearly in the United States, more than half of which could have been prevented with broader use of HIV pre-exposure prophylaxis (PrEP). We aimed to qualitatively assess (1) acceptability of an HIV risk screening strategy and PrEP provision in a family planning setting, and (2) the influence of family planning visit type (abortion, pregnancy loss management, or contraception) on HIV risk screening acceptability. STUDY DESIGN Guided by the P3 (practice-, provider-, and patient-level) model for preventive care interventions, we conducted three focus group discussions including patients who had experienced induced abortion, early pregnancy loss (EPL), or contraception care. We developed a codebook of a priori and inductive concepts, and categorized themes by practice, provider, and patient considerations. RESULTS We included 24 participants. Practice-level considerations included overall positive feelings about being screened for PrEP eligibility during family planning visits, though some expressed reservations about screening during EPL visits. Provider-level themes included the concept of screening tools as entry points into conversation and education, and the importance of nonjudgment in discussing sexually transmitted infection (STI) prevention. Participants often had to initiate STI prevention discussions and felt that contraception was overemphasized by their providers compared with STI prevention and PrEP care. Patient-level themes included the stigma of STIs and oral PrEP, and the dynamic nature of STI risk. CONCLUSIONS Participants in our research had genuine interest in learning about PrEP during family planning visits. Findings from our research support the consistent inclusion of STI prevention education into family planning clinical practice using patient-centered STI screening methods. IMPLICATIONS Family planning encounters, including visits for contraception and abortion, are generally appropriate times to discuss HIV PrEP. Patient-centered conversations are an important adjunct to HIV risk screening tools.
Collapse
Affiliation(s)
- Sarita Sonalkar
- Department of Obstetrics and Gynecology, Division of Family Planning, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA.
| | - Corinne Kete
- Department of Obstetrics and Gynecology, Division of Family Planning, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Arden McAllister
- Department of Obstetrics and Gynecology, Division of Family Planning, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Ryan Afreen
- University of Pennsylvania, School of Arts and Sciences, Philadelphia, USA
| | - Jason Kaufman
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - William Short
- Department of Medicine, Division of Infectious Diseases, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Shimrit Keddem
- Department of Family Medicine and Community Health, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA; Veterans Affairs Center for Health Equity, Research & Promotion, Micheal J. Crescenz Veterans Affairs Medical Center, Philadelphia, USA
| |
Collapse
|
7
|
Keddem S, Agha A, Morawej S, Buck A, Cronholm P, Sonalkar S, Kearney M. Characterizing Twitter Content About HIV Pre-exposure Prophylaxis (PrEP) for Women: Qualitative Content Analysis. J Med Internet Res 2023; 25:e43596. [PMID: 37166954 PMCID: PMC10214116 DOI: 10.2196/43596] [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: 10/17/2022] [Revised: 04/24/2023] [Accepted: 04/25/2023] [Indexed: 05/12/2023] Open
Abstract
BACKGROUND HIV remains a persistent health problem in the United States, especially among women. Approved in 2012, HIV pre-exposure prophylaxis (PrEP) is a daily pill or bimonthly injection that can be taken by individuals at increased risk of contracting HIV to reduce their risk of new infection. Women who are at risk of HIV face numerous barriers to HIV services and information, underscoring the critical need for strategies to increase awareness of evidence-based HIV prevention methods, such as HIV PrEP, among women. OBJECTIVE We aimed to identify historical trends in the use of Twitter hashtags specific to women and HIV PrEP and explore content about women and PrEP shared through Twitter. METHODS This was a qualitative descriptive study using a purposive sample of tweets containing hashtags related to women and HIV PrEP from 2009 to 2022. Tweets were collected via Twitter's API. Each Twitter user profile, tweet, and related links were coded using content analysis, guided by the framework of the Health Belief Model (HBM) to generate results. We used a factor analysis to identify salient clusters of tweets. RESULTS A total of 1256 tweets from 396 unique users were relevant to our study focus of content about PrEP specifically for women (1256/2908, 43.2% of eligible tweets). We found that this sample of tweets was posted mostly by organizations. The 2 largest groups of individual users were activists and advocates (61/396, 15.4%) and personal users (54/396, 13.6%). Among individual users, most were female (100/166, 60%) and American (256/396, 64.6%). The earliest relevant tweet in our sample was posted in mid-2014 and the number of tweets significantly decreased after 2018. We found that 61% (496/820) of relevant tweets contained links to informational websites intended to provide guidance and resources or promote access to PrEP. Most tweets specifically targeted people of color, including through the use of imagery and symbolism. In addition to inclusive imagery, our factor analysis indicated that more than a third of tweets were intended to share information and promote PrEP to people of color. Less than half of tweets contained any HBM concepts, and only a few contained cues to action. Lastly, while our sample included only tweets relevant to women, we found that the tweets directed to lesbian, gay, bisexual, transgender, queer (LGBTQ) audiences received the highest levels of audience engagement. CONCLUSIONS These findings point to several areas for improvement in future social media campaigns directed at women about PrEP. First, future posts would benefit from including more theoretical constructs, such as self-efficacy and cues to action. Second, organizations posting on Twitter should continue to broaden their audience and followers to reach more people. Lastly, tweets should leverage the momentum and strategies used by the LGBTQ community to reach broader audiences and destigmatize PrEP use across all communities.
Collapse
Affiliation(s)
- Shimrit Keddem
- Department of Family Medicine & Community Health, University of Pennsylvania, Philadelphia, PA, United States
- Center for Health Equity, Research & Promotion, Corporal Michael J Crescenz VA Medical Center, US Department of Veterans Affairs, Philadelphia, PA, United States
| | - Aneeza Agha
- Center for Health Equity, Research & Promotion, Corporal Michael J Crescenz VA Medical Center, US Department of Veterans Affairs, Philadelphia, PA, United States
| | - Sabrina Morawej
- Center for Health Equity, Research & Promotion, Corporal Michael J Crescenz VA Medical Center, US Department of Veterans Affairs, Philadelphia, PA, United States
| | - Amy Buck
- Center for Public Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Peter Cronholm
- Department of Family Medicine & Community Health, University of Pennsylvania, Philadelphia, PA, United States
- Center for Public Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
- Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, PA, United States
| | - Sarita Sonalkar
- Division of Family Planning, Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Matthew Kearney
- Department of Family Medicine & Community Health, University of Pennsylvania, Philadelphia, PA, United States
- Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, PA, United States
| |
Collapse
|
8
|
Flynn A, Galvao R, Joslin I, McAllister A, C Koelper N, Sonalkar S. Exploring technology-based interventions to improve oral contraceptive pill adherence: a cross-sectional survey. EUR J CONTRACEP REPR 2023:1-4. [PMID: 37013727 DOI: 10.1080/13625187.2023.2191763] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023]
Abstract
PURPOSE To assess the resources that oral contraceptive pill (OCP) users currently use and wish to use after missing pills. MATERIALS AND METHODS People 18-44 years old with a OCP prescription were emailed a cross-sectional survey to assess how they obtain information about managing missed pills, what information they would prefer to access, and whether they would use additional information if it were available. We performed a logistic regression and a dominance analysis to compare independent predictors of desire for a technological resource at the time of missed pills. RESULTS We received 166 completed surveys. Nearly half of participants (47%, n = 76, 95% CI 39.0-54.4%) did not seek information about managing their missed pills. When missing a pill, more patients preferred non-technology-based information (57.1%, n = 93, 95% CI 49.3-64.5%) over technology-based information (43%, n = 70, 95% CI 35.5-50.7%). Most reported they would appreciate more information at the time of missed pills (76%, n = 124, 95% CI 68.9-82.0%). The strongest predictors for desire for technology-based information were: current use of technology, lower parity, white race, and higher educational attainment. CONCLUSIONS This study indicates that most OCP users would utilise additional information at the time of a missed pill if they had access to it and that they desire information in varying formats.
Collapse
Affiliation(s)
- Anne Flynn
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Rachel Galvao
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Isabella Joslin
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Arden McAllister
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Nathanael C Koelper
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Sarita Sonalkar
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|
9
|
Sonalkar S, Gilmore E. A fresh look at treatment for ectopic pregnancy. Lancet 2023; 401:619-620. [PMID: 36738758 DOI: 10.1016/s0140-6736(23)00181-2] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 01/19/2023] [Indexed: 02/04/2023]
Affiliation(s)
- Sarita Sonalkar
- Department of Obstetrics and Gynecology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA.
| | - Emma Gilmore
- Department of Obstetrics and Gynecology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA
| |
Collapse
|
10
|
Schwarz EB, Gariepy A, Sonalkar S. Comparing IUC and Tubal Ligation. J Gen Intern Med 2023; 38:240. [PMID: 36271169 PMCID: PMC9849622 DOI: 10.1007/s11606-022-07845-2] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 10/06/2022] [Indexed: 01/22/2023]
|
11
|
Sonalkar S, Kete C, Afreen R, McAllister A, Kaufman J, Keddem S. P090Perceptions of hiv risk screening strategies among patients seeking abortion, contraception, and pregnancy loss management. Contraception 2022. [DOI: 10.1016/j.contraception.2022.09.114] [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]
|
12
|
Nagendra D, Gutman SM, Koelper NC, Loza-Avalos SE, Sonalkar S, Schreiber CA, Harvie HS. Medical management of early pregnancy loss is cost-effective compared with office uterine aspiration. Am J Obstet Gynecol 2022; 227:737.e1-737.e11. [PMID: 35780811 PMCID: PMC10302401 DOI: 10.1016/j.ajog.2022.06.054] [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: 01/28/2022] [Revised: 06/17/2022] [Accepted: 06/26/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Early pregnancy loss, also referred to as miscarriage, is common, affecting approximately 1 million people in the United States annually. Early pregnancy loss can be treated with expectant management, medications, or surgical procedures-strategies that differ in patient experience, effectiveness, and cost. One of the medications used for early pregnancy loss treatment, mifepristone, is uniquely regulated by the Food and Drug Administration. OBJECTIVE This study aimed to compare the cost-effectiveness from the healthcare sector perspective of medical management of early pregnancy loss, using the standard of care medication regimen of mifepristone and misoprostol, with that of office uterine aspiration. STUDY DESIGN We developed a decision analytical model to compare the cost-effectiveness of early pregnancy loss treatment with medical management with that of office uterine aspiration. Data on medical management came from the Pregnancy Failure Regimens randomized clinical trial, and data on uterine aspiration came from the published literature. The analysis was from the healthcare sector perspective with a 30-day time horizon. Costs were in 2018 US dollars. Effectiveness was measured in quality-adjust life-years gained and the rate of complete gestational sac expulsion with no additional interventions. Our primary outcome was the incremental cost per quality-adjust life-year gained. Sensitivity analysis was performed to identify the key uncertainties. RESULTS Mean per-person costs were higher for uterine aspiration than for medical management ($828 [95% confidence interval, $789-$868] vs $661 [95% confidence interval, $556-$766]; P=.004). Uterine aspiration more frequently led to complete gestational sac expulsion than medical management (97.3% vs 83.8%; P=.0001); however, estimated quality-adjust life-years were higher for medical management than for uterine aspiration (0.082 [95% confidence interval, 0.8148-0.08248] vs 0.079 [95% confidence interval, 0.0789-0.0791]; P<.0001). Medical management dominated uterine aspiration, with lower costs and higher confidence interval. The probability that medical management is cost-effective relative to uterine aspiration is 97.5% for all willingness-to-pay values of ≥$5600/quality-adjust life-year. Sensitivity analysis did not identify any thresholds that would substantially change outcomes. CONCLUSION Although office-based uterine aspiration more often results in treatment completion without further intervention, medical management with mifepristone pretreatment costs less and yields similar quality-adjust life-years, making it an attractive alternative. Our findings provided evidence that increasing access to mifepristone and eliminating unnecessary restrictions will improve early pregnancy care.
Collapse
Affiliation(s)
- Divyah Nagendra
- Department of Obstetrics and Gynecology, Cambridge Health Alliance, Cambridge, MA; Department of Obstetrics and Gynecology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Sarah M Gutman
- Department of Obstetrics and Gynecology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.
| | - Nathanael C Koelper
- Department of Obstetrics and Gynecology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Sandra E Loza-Avalos
- Department of Obstetrics and Gynecology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Sarita Sonalkar
- Department of Obstetrics and Gynecology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Courtney A Schreiber
- Department of Obstetrics and Gynecology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Heidi S Harvie
- Department of Obstetrics and Gynecology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| |
Collapse
|
13
|
Mulugeta-Gordon L, Haggerty A, Smith AJ, Mastroyannis SA, Sonalkar S, James A, Flynn A, Ko E. Measuring health disparity index in gynecologic oncology (281). Gynecol Oncol 2022. [DOI: 10.1016/s0090-8258(22)01502-5] [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: 11/16/2022]
|
14
|
Sonalkar S, McAllister A, Kete C, Fishman J, Frarey A, Short WR, Schreiber CA, Teitelman AM. Implementation of an HIV Pre-exposure Prophylaxis Strategy Into Abortion and Early Pregnancy Loss Care. J Acquir Immune Defic Syndr 2022; 90:S129-S133. [PMID: 35703764 PMCID: PMC9204783 DOI: 10.1097/qai.0000000000002972] [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: 11/26/2022]
Abstract
BACKGROUND Family planning and abortion clinics routinely address sexual health. We sought to evaluate implementation outcomes of an HIV pre-exposure prophylaxis (PrEP) care strategy for patients seeking management of induced abortion and pregnancy loss. SETTING Single-center, urban, academic, hospital-based family planning service. METHODS We used a multifaceted implementation strategy directed toward family planning providers comprised of educational sessions, an electronic medical record-prompted verbal assessment of HIV risk, electronic medical record shortcuts for PrEP prescription, and support of a PrEP navigator. We assessed penetration of the intervention by calculating the penetration of a PrEP offer, measured as the proportion of encounters in which PrEP was offered to PrEP-eligible individuals. We evaluated feasibility, acceptability, and appropriateness of the intervention using belief elicitation interviews with providers. RESULTS From November 2018 to April 2019, the proportion of PrEP eligible patients who were offered PrEP, was 87.9% (29/33). Providers found the intervention acceptable and appropriate, but reported barriers including time constraints, and disappointment if patients did not adhere to PrEP. Providers liked that PrEP provision in abortion care settings felt innovative, and that they could contribute to HIV prevention. CONCLUSION Family planning providers in an academic center found HIV risk assessment and PrEP provision to be feasible, acceptable, and appropriate. Further research should evaluate implementation outcomes of PrEP care strategies in additional abortion care contexts, including clinics offering reproductive health care outside of academia.
Collapse
Affiliation(s)
- Sarita Sonalkar
- Division of Family Planning, Perelman School of Medicine at the University of Pennsylvania, 3737 Market St, 12 Floor, Philadelphia, PA 19119, USA, 215-615-5234
| | - Arden McAllister
- Division of Family Planning, Perelman School of Medicine at the University of Pennsylvania, 3737 Market St, 12 Floor, Philadelphia, PA 19119, USA, 215-615-5234
| | - Corinne Kete
- Division of Family Planning, Perelman School of Medicine at the University of Pennsylvania, 3737 Market St, 12 Floor, Philadelphia, PA 19119, USA, 215-615-5234
| | - Jessica Fishman
- Department of Psychiatry, Perelman School of Medicine; Annenberg School for Communication, 3620 Walnut Street, Philadelphia, PA 19104; Leonard Davis Institute, University of Pennsylvania
| | - Alhambra Frarey
- Division of Family Planning, Perelman School of Medicine at the University of Pennsylvania, 3737 Market St, 12 Floor, Philadelphia, PA 19119, USA, 215-615-5234
| | - William R. Short
- Division of Infectious Diseases, Perelman School of Medicine at the University of Pennsylvania, 3801 Filbert Street, Suite 103, Philadelphia, PA 19104, 215-662-9908
| | - Courtney A. Schreiber
- Division of Family Planning, Perelman School of Medicine at the University of Pennsylvania, 3737 Market St, 12 Floor, Philadelphia, PA 19119, USA, 215-615-5234
| | - Anne M. Teitelman
- School of Nursing, University of Pennsylvania, Claire M. Fagin Hall, 418 Curie Blvd, Philadelphia, PA 19104
| |
Collapse
|
15
|
Sonalkar S, Short WR, McAllister A, Kete C, Ingeno L, Fishman J, Koenig HC, Schreiber CA, Teitelman AM. Incorporating HIV Pre-Exposure Prophylaxis Care for Patients Seeking Induced Abortion and Pregnancy Loss Management. Womens Health Issues 2022; 32:388-394. [PMID: 34998653 DOI: 10.1016/j.whi.2021.12.005] [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: 05/26/2021] [Revised: 12/03/2021] [Accepted: 12/13/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Family planning clinical encounters are important opportunities for HIV prevention. Our objectives were to 1) estimate the proportion of patients seeking induced abortion and early pregnancy loss management eligible for HIV pre-exposure prophylaxis (PrEP) and 2) compare PrEP eligibility and uptake between patients with unintended and intended pregnancy. METHODS We conducted a cross-sectional survey and a nested prospective cohort study of patients seeking an induced abortion or early pregnancy loss management. We assessed pregnancy intendedness, PrEP awareness, HIV risk and risk perception, desire for same-day PrEP start, and PrEP continuation at 30 days. We used the χ2 and Fisher's exact tests to assess differences between the participants with intended and unintended pregnancy. We had 80% power to detect a 14% difference in PrEP eligibility between the groups. RESULTS We enrolled 250 women. Fifty-six percent (139) had an unintended pregnancy and 44% (110) had an intended pregnancy. PrEP eligibility did not differ significantly between the patients with intended and unintended pregnancy (16% vs. 10%; p = .18). More than one-half (54%, 135/250) were unaware of PrEP before their study visit, and 93% (232/250) considered themselves unlikely to acquire HIV. Of 33 women who were PrEP eligible, 11 accepted same-day start and 1 continued PrEP at 30 days. CONCLUSIONS Intendedness of pregnancy was unrelated to PrEP eligibility in women seeking induced abortion and early pregnancy loss management. Most patients seeking these services are unaware of PrEP. Integrating PrEP into family planning care is likely to increase awareness and uptake of PrEP in women.
Collapse
Affiliation(s)
- Sarita Sonalkar
- Division of Family Planning, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
| | - William R Short
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania
| | - Arden McAllister
- Division of Family Planning, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Corinne Kete
- Division of Family Planning, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Leah Ingeno
- Division of Family Planning, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jessica Fishman
- Department of Psychiatry, Perelman School of Medicine, Philadelphia, Pennsylvania; Annenberg School for Communication, Philadelphia, Pennsylvania; Leonard Davis Institute, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Helen C Koenig
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania
| | - Courtney A Schreiber
- Division of Family Planning, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Anne M Teitelman
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania
| |
Collapse
|
16
|
Keddem S, Dichter ME, Hamilton AB, Chhatre S, Sonalkar S. Awareness of HIV Preexposure Prophylaxis Among People at Risk for HIV: Results From the 2017-2019 National Survey of Family Growth. Sex Transm Dis 2021; 48:967-972. [PMID: 34108411 DOI: 10.1097/olq.0000000000001494] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Although daily preexposure prophylaxis (PrEP) is now widely accepted as a safe and effective method for reducing the risk of HIV in high-risk groups, uptake has been slow. The goal of this analysis was to identify factors associated with PrEP awareness among individuals at risk for HIV. METHODS This investigation analyzed data from the Centers for Disease Control and Prevention nationally representative survey, National Survey of Family Growth, for the years 2017 to 2019. Logistic regression was used to explore the relationship between PrEP awareness and demographics, HIV risk factors, and provider HIV risk screening. RESULTS Only 37% of survey respondents with an increased risk of HIV were aware of PrEP. Several segments of the at-risk population had lower odds of being aware of PrEP, including heterosexual women, heterosexual men, individuals younger than 20 years, and individuals with lower levels of education. Those who participate in sex in exchange for money or drugs had significantly lower odds of being aware of PrEP. In comparison, PrEP awareness was significantly higher among nonheterosexual men and both men and women whose partners were HIV positive. Lastly, those who had been screened by a provider for HIV risk had significantly higher odds of being aware of PrEP. CONCLUSIONS This research supports the need for policies and programs to increase awareness of PrEP, especially among certain segments of the population at increased risk for HIV.
Collapse
Affiliation(s)
| | | | | | | | - Sarita Sonalkar
- From the Perelman School of Medicine, University of Pennsylvania
| |
Collapse
|
17
|
Albright BB, Myers ER, Moss HA, Ko EM, Sonalkar S, Havrilesky LJ. Surveillance for gestational trophoblastic neoplasia following molar pregnancy: a cost-effectiveness analysis. Am J Obstet Gynecol 2021; 225:513.e1-513.e19. [PMID: 34058170 PMCID: PMC9941751 DOI: 10.1016/j.ajog.2021.05.031] [Citation(s) in RCA: 3] [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: 03/15/2021] [Revised: 05/24/2021] [Accepted: 05/24/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Historically, published guidelines for care after molar pregnancy recommended monitoring human chorionic gonadotropin levels for the development of gestational trophoblastic neoplasia until normal and then for 6 months after the first normal human chorionic gonadotropin. However, there are little data underlying such recommendations, and recent evidence has demonstrated that gestational trophoblastic neoplasia diagnosis after human chorionic gonadotropin normalization is rare. OBJECTIVE We sought to estimate the cost-effectiveness of alternative strategies for surveillance for gestational trophoblastic neoplasia after human chorionic gonadotropin normalization after complete and partial molar pregnancy. STUDY DESIGN A Markov-based cost-effectiveness model, using monthly cycles and terminating after 36 months/cycles, was constructed to compare alternative strategies for asymptomatic human chorionic gonadotropin surveillance after the first normal (none; monthly testing for 1, 3, 6, and 12 months; or every 3-month testing for 3, 6, and 12 months) for both complete and partial molar pregnancy. The risk of reduced surveillance was modeled by increasing the probability of high-risk disease at diagnosis. Probabilities, costs, and utilities were estimated from peer-reviewed literature, with all cost data applicable to the United States and adjusted to 2020 US dollars. The primary outcome was cost per quality-adjusted life year ($/quality-adjusted life year) with a $100,000/quality-adjusted life year willingness-to-pay threshold. RESULTS Under base-case assumptions, we found no further surveillance after the first normal human chorionic gonadotropin to be the dominant strategy from both the healthcare system and societal perspectives, for both complete and partial molar pregnancy. After complete mole, this strategy had the lowest average cost (healthcare system, $144 vs maximum $283; societal, $152 vs maximum $443) and highest effectiveness (2.711 vs minimum 2.682 quality-adjusted life years). This strategy led to a slightly higher rate of death from gestational trophoblastic neoplasia (0.013% vs minimum 0.009%), although with high costs per gestational trophoblastic neoplasia death avoided (range, $214,000 to >$4 million). Societal perspective costs of lost wages had a greater impact on frequent surveillance costs than rare gestational trophoblastic neoplasia treatment costs, and no further surveillance was more favorable from this perspective in otherwise identical analyses. No further surveillance remained dominant or preferred with incremental cost-effectiveness ratio of <$100,000 in all analyses for partial mole, and most sensitivity analyses for complete mole. Under the assumption of no disutility from surveillance, surveillance strategies were more effective (by quality-adjusted life year) than no further surveillance, and a single human chorionic gonadotropin test at 3 months was found to be cost-effective after complete mole with incremental cost-effectiveness ratio of $53,261 from the healthcare perspective, but not from the societal perspective (incremental cost-effectiveness ratio, $288,783). CONCLUSION Largely owing to the rare incidence of gestational trophoblastic neoplasia after human chorionic gonadotropin normalization after molar pregnancy, prolonged surveillance is not cost-effective under most assumptions. It would be reasonable to reduce, and potentially eliminate, current recommendations for surveillance after human chorionic gonadotropin normalization after molar pregnancy, particularly among partial moles. With any reduction in surveillance, patients should be counseled on symptoms of gestational trophoblastic neoplasia and established in routine gynecologic care.
Collapse
Affiliation(s)
- Benjamin B Albright
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC.
| | - Evan R Myers
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC
| | - Haley A Moss
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC
| | - Emily M Ko
- Department of Obstetrics and Gynecology, University of Pennsylvania Health System, Philadelphia, PA
| | - Sarita Sonalkar
- Department of Obstetrics and Gynecology, University of Pennsylvania Health System, Philadelphia, PA
| | - Laura J Havrilesky
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC
| |
Collapse
|
18
|
Flynn AN, Allen A, Gutman S, Seth-McCoy N, Sonalkar S. POSTER ABSTRACTS. Contraception 2021. [DOI: 10.1016/j.contraception.2021.07.056] [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: 10/20/2022]
|
19
|
Chesnokova A, Gallop R, Koelper N, Sonalkar S. POSTER ABSTRACTS. Contraception 2021. [DOI: 10.1016/j.contraception.2021.07.072] [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: 11/15/2022]
|
20
|
Sonalkar S, Fishman J, Kete C, McAllister A, Frarey A, Short WR, Schreiber CA, Teitelman A. ORAL ABSTRACTS. Contraception 2021. [DOI: 10.1016/j.contraception.2021.07.011] [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: 10/20/2022]
|
21
|
Burlando AM, Flynn AN, Gutman S, McAllister A, Roe AH, Schreiber CA, Sonalkar S. The Role of Subcutaneous Depot Medroxyprogesterone Acetate in Equitable Contraceptive Care: A Lesson From the Coronavirus Disease 2019 (COVID-19) Pandemic. Obstet Gynecol 2021; 138:574-577. [PMID: 34623069 PMCID: PMC8454279 DOI: 10.1097/aog.0000000000004524] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 06/17/2021] [Indexed: 11/26/2022]
Abstract
Since the beginning of the coronavirus disease 2019 (COVID-19) pandemic, health care professionals have made swift accommodations to provide consistent and safe care, including emphasizing remote access to allow physical distancing. Depot medroxyprogesterone acetate intramuscular injection (DMPA-IM) prescription is typically administered by a health care professional, whereas DMPA-subcutaneous has the potential to be safely self-injected by patients, avoiding contact with a health care professional. However, DMPA-subcutaneous is rarely prescribed despite its U.S. Food and Drug Administration approval in 2004 and widespread coverage by both state Medicaid providers and many private insurers. Depot medroxyprogesterone acetate users are disproportionately non-White, and thus the restriction in DMPA-subcutaneous prescribing may both stem from and contribute to systemic racial health disparities. We review evidence on acceptability, safety, and continuation rates of DMPA-subcutaneous, consider sources of implicit bias that may impede prescription of this contraceptive method, and provide recommendations for implementing DMPA-subcutaneous prescribing.
Collapse
Affiliation(s)
- Audrey M Burlando
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | | | | | | | | | | |
Collapse
|
22
|
Barnhart KT, Hansen KR, Stephenson MD, Usadi R, Steiner AZ, Cedars MI, Jungheim ES, Hoeger KM, Krawetz SA, Mills B, Alston M, Coutifaris C, Senapati S, Sonalkar S, Diamond MP, Wild RA, Rosen M, Sammel MD, Santoro N, Eisenberg E, Huang H, Zhang H. Effect of an Active vs Expectant Management Strategy on Successful Resolution of Pregnancy Among Patients With a Persisting Pregnancy of Unknown Location: The ACT or NOT Randomized Clinical Trial. JAMA 2021; 326:390-400. [PMID: 34342619 PMCID: PMC8335579 DOI: 10.1001/jama.2021.10767] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [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: 11/14/2022]
Abstract
IMPORTANCE Women with an early nonviable pregnancy of unknown location are at high risk of ectopic pregnancy and its inherent morbidity and mortality. Successful and timely resolution of the gestation, while minimizing unscheduled interventions, are important priorities. OBJECTIVE To determine if active management is more effective in achieving pregnancy resolution than expectant management and whether the use of empirical methotrexate is noninferior to uterine evacuation followed by methotrexate if needed. DESIGN, SETTING, AND PARTICIPANTS This multicenter randomized clinical trial recruited 255 hemodynamically stable women with a diagnosed persisting pregnancy of unknown location between July 25, 2014, and June 4, 2019, in 12 medical centers in the United States (final follow up, August 19, 2019). INTERVENTIONS Eligible patients were randomized in a 1:1:1 ratio to expectant management (n = 86), active management with uterine evacuation followed by methotrexate if needed (n = 87), or active management with empirical methotrexate using a 2-dose protocol (n = 82). MAIN OUTCOMES AND MEASURES The primary outcome was successful resolution of the pregnancy without change from initial strategy. The primary hypothesis tested for superiority of the active groups combined vs expectant management, and a secondary hypothesis tested for noninferiority of empirical methotrexate compared with uterine evacuation with methotrexate as needed using a noninferiority margin of -12%. RESULTS Among 255 patients who were randomized (median age, 31 years; interquartile range, 27-36 years), 253 (99.2%) completed the trial. Ninety-nine patients (39%) declined their randomized allocation (26.7% declined expectant management, 48.3% declined uterine evacuation, and 41.5% declined empirical methotrexate) and crossed over to a different group. Compared with patients randomized to receive expectant management (n = 86), women randomized to receive active management (n = 169) were significantly more likely to experience successful pregnancy resolution without change in their initial management strategy (51.5% vs 36.0%; difference, 15.4% [95% CI, 2.8% to 28.1%]; rate ratio, 1.43 [95% CI, 1.04 to 1.96]). Among active management strategies, empirical methotrexate was noninferior to uterine evacuation followed by methotrexate if needed with regard to successful pregnancy resolution without change in management strategy (54.9% vs 48.3%; difference, 6.6% [1-sided 97.5% CI, -8.4% to ∞]). The most common adverse event was vaginal bleeding for all of the 3 management groups (44.2%-52.9%). CONCLUSIONS AND RELEVANCE Among patients with a persisting pregnancy of unknown location, patients randomized to receive active management, compared with those randomized to receive expectant management, more frequently achieved successful pregnancy resolution without change from the initial management strategy. The substantial crossover between groups should be considered when interpreting the results. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02152696.
Collapse
Affiliation(s)
- Kurt T Barnhart
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Karl R Hansen
- Department of Obstetrics and Gynecology, University of Oklahoma Health Sciences Center, Oklahoma City
| | - Mary D Stephenson
- Department of Obstetrics and Gynecology, University of Illinois at Chicago
| | - Rebecca Usadi
- Department of Obstetrics and Gynecology, Atrium Health, Charlotte, North Carolina
| | - Anne Z Steiner
- Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill
| | - Marcelle I Cedars
- Department of Obstetrics and Gynecology, University of California at San Francisco
| | - Emily S Jungheim
- Department of Obstetrics and Gynecology, Northwestern University, Chicago, Illinois
| | - Kathleen M Hoeger
- Department of Obstetrics and Gynecology, University of Rochester, Rochester, New York
| | - Stephen A Krawetz
- Department of Obstetrics and Gynecology and Center for Molecular Medicine and Genetics, Wayne State University, Detroit, Michigan
| | - Benjie Mills
- Department of Obstetrics & Gynecology, Prisma Health, University of South Carolina School of Medicine-Greenville
| | - Meredith Alston
- Department of Obstetrics and Gynecology, University of Colorado and Denver Health Medical Center, Denver
| | - Christos Coutifaris
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Suneeta Senapati
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sarita Sonalkar
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael P Diamond
- Department of Obstetrics and Gynecology, Augusta University, Augusta, Georgia
| | - Robert A Wild
- Department of Obstetrics and Gynecology, University of Oklahoma Health Sciences Center, Oklahoma City
| | - Mitchell Rosen
- Department of Obstetrics and Gynecology, University of California at San Francisco
| | - Mary D Sammel
- Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora
| | - Nanette Santoro
- Department of Obstetrics and Gynecology, University of Colorado, Denver
| | - Esther Eisenberg
- Fertility and Infertility Branch, National Institute of Child Health and Human Development, Rockville, Maryland
| | - Hao Huang
- Department of Biostatistics, Yale University, New Haven, Connecticut
| | - Heping Zhang
- Department of Biostatistics, Yale University, New Haven, Connecticut
| | | |
Collapse
|
23
|
Sonalkar S, Maya E, Adanu R, Samba A, Mumuni K, McAllister A, Fishman J, Schurr D, Schreiber CA, Kolev S, Doe R, Eluned Gaffield M. Pilot monitoring and evaluation of the WHO postpartum family planning compendium mobile application: An in-depth, qualitative study. Int J Gynaecol Obstet 2021; 153:508-513. [PMID: 33513267 DOI: 10.1002/ijgo.13631] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 10/06/2020] [Accepted: 11/27/2020] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To assess the feasibility, functionality and acceptability of a mobile application (app), the World Health Organization (WHO) Postpartum Family Planning (PPFP) Compendium, in clinical care. METHOD This prospective qualitative study was conducted among family planning providers routinely delivering PPFP care in Accra, Ghana. We conducted in-depth interviews at baseline and 3 months after app introduction. We elicited expected technological, psychological and environmental barriers to use, actual use in clinical settings, and feedback for app improvement. With inter-coder reliability, we analyzed the content of interview transcripts. RESULTS Twenty providers participated in baseline interviews, and 19 participated in follow-up interviews. At baseline, providers did not have significant technological barriers to its use and felt the app was acceptable, but were concerned about the appropriateness of using an app during clinical care. At 3-month follow-up, 18 out of 19 participants reported using the app weekly, and found the app acceptable for use in clinical care. Providers recommended expanding clinical content and including similar guidance relevant to times outside the postpartum period. CONCLUSION Use of a PPFP counseling app to aid family planning providers in clinical care delivery is feasible and acceptable. Providers recommended inclusion of similar guidance relevant to times outside the postpartum period.
Collapse
Affiliation(s)
- Sarita Sonalkar
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Ernest Maya
- University of Ghana School of Public Health, Accra, Ghana
| | - Richard Adanu
- University of Ghana School of Public Health, Accra, Ghana
| | - Ali Samba
- University of Ghana School of Medicine and Dentistry, Accra, Ghana
| | - Kareem Mumuni
- University of Ghana School of Medicine and Dentistry, Accra, Ghana
| | - Arden McAllister
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Jessica Fishman
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA.,Annenberg School for Communication, University of Pennsylvania, Philadelphia, USA
| | - Danielle Schurr
- Annenberg School for Communication, University of Pennsylvania, Philadelphia, USA
| | | | | | | | | |
Collapse
|
24
|
Flynn AN, Schreiber CA, Roe A, Shorter JM, Frarey A, Barnhart K, Sonalkar S. Prioritizing Desiredness in Pregnancy of Unknown Location: An Algorithm for Patient-Centered Care. Obstet Gynecol 2020; 136:1001-1005. [PMID: 33030869 DOI: 10.1097/aog.0000000000004124] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Patient-centered care is one of the six aims for improvement in health care quality outlined by the National Academy of Medicine (previously known as the Institute of Medicine). We propose an algorithm for patients who are presenting with a pregnancy of unknown location that emphasizes pregnancy desiredness to improve patient-centered care. Health care professionals should assess pregnancy desiredness at a patient's initial consultation for evaluation of pregnancy of unknown location; desiredness, along with other clinical criteria, should guide management. For women with an undesired pregnancy, health care professionals should offer expedient active management. Uterine aspiration will allow for quick clinical diagnosis and resolution of the pregnancy. Alternatively, for women with a desired pregnancy or for those who are ambivalent, we recommend careful conservative management. Adopting this algorithm will recenter the patient in the complex management of pregnancy of unknown location.
Collapse
Affiliation(s)
- Anne N Flynn
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | | | | | | | | | | |
Collapse
|
25
|
Gurney EP, McAllister A, Lang B, Schreiber CA, Sonalkar S. Ultrasound assessment of postplacental copper intrauterine device position 6 months after placement during cesarean delivery. Contracept X 2020; 2:100040. [PMID: 33196037 PMCID: PMC7644571 DOI: 10.1016/j.conx.2020.100040] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 09/14/2020] [Accepted: 09/16/2020] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE The objective was to describe the sonographic position of copper intrauterine devices (IUDs) 6 months after insertion during cesarean delivery. STUDY DESIGN This prospective, observational study followed participants who received a copper IUD during cesarean delivery. We performed pelvic examination at 6 weeks and 6 months and sonography at 6 months to determine IUD position. Patients had additional examinations as needed to address complications. RESULTS Sixty-nine participants provided outcomes through 6 months: 41 (59%) had correctly positioned IUDs, 21 (30%) had malpositioned intrauterine IUDs, 5 experienced expulsion (3 partial, 2 complete), and 2 had elective removal; 52 (75%) had missing strings. Missing strings at 6 weeks predicted an incorrect IUD position in 22 of 52 participants (positive predictive value 42%), and visible or palpable strings predicted a correct IUD position in 7 of 12 participants (negative predictive value 58%). CONCLUSION Although 59% of copper IUDs placed during cesarean were correctly positioned at 6 months, nearly one third were malpositioned. IMPLICATIONS Ultrasound may be indicated for patients receiving a copper IUD during cesarean delivery as checking IUD strings alone does not assure correct placement. Providers offering postpartum IUDs should ensure that appropriate processes for the evaluation and management of devices with missing strings or abnormal position are available to all patients regardless of insurance status.
Collapse
Affiliation(s)
| | - Arden McAllister
- Perelman School of Medicine at the University of Pennsylvania, Family Planning Division, Department of Obstetrics and Gynecology, 1000 Courtyard, 3400 Spruce St., Philadelphia, PA 19104
| | - Britt Lang
- Perelman School of Medicine at the University of Pennsylvania, Family Planning Division, Department of Obstetrics and Gynecology, 1000 Courtyard, 3400 Spruce St., Philadelphia, PA 19104
| | - Courtney A. Schreiber
- Perelman School of Medicine at the University of Pennsylvania, Family Planning Division, Department of Obstetrics and Gynecology, 1000 Courtyard, 3400 Spruce St., Philadelphia, PA 19104
| | - Sarita Sonalkar
- Perelman School of Medicine at the University of Pennsylvania, Family Planning Division, Department of Obstetrics and Gynecology, 1000 Courtyard, 3400 Spruce St., Philadelphia, PA 19104
| |
Collapse
|
26
|
Gariepy A, Dove M, Lewis C, Zuckerman D, Tancredi D, McDonald-Mosley R, Sonalkar S, Hathaway M, Nunez-Eddy C, Schwarz E. P75 Rates of procedural complications and patient-centered outcomes after publicly-funded hysteroscopic or laparoscopic sterilization in California. Contraception 2020. [DOI: 10.1016/j.contraception.2020.07.096] [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: 11/28/2022]
|
27
|
Chesnokova A, Nagendra D, Schreiber C, Sonalkar S. P25 Exploring the association between trust in provider and abortion stigma in the second trimester. Contraception 2020. [DOI: 10.1016/j.contraception.2020.07.044] [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: 11/26/2022]
|
28
|
Sonalkar S, Koelper N, Creinin MD, Atrio JM, Sammel MD, McAllister A, Schreiber CA. Management of early pregnancy loss with mifepristone and misoprostol: clinical predictors of treatment success from a randomized trial. Am J Obstet Gynecol 2020; 223:551.e1-551.e7. [PMID: 32305259 DOI: 10.1016/j.ajog.2020.04.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 03/31/2020] [Accepted: 04/10/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Early pregnancy loss is a common event in the first trimester, occurring in 15%-20% of confirmed pregnancies. A common evidence-based medical regimen for early pregnancy loss uses misoprostol, a prostaglandin E1 analog, with a dosage of 800 μg, self-administered vaginally. The clinical utility of this regimen is limited by suboptimal effectiveness in patients with a closed cervical os, with 29% of patients experiencing early pregnancy loss requiring a second dose after 3 days and 16% of patients eventually requiring a uterine aspiration procedure. OBJECTIVE This study aimed to evaluate clinical predictors associated with treatment success in patients receiving medical management with mifepristone-misoprostol or misoprostol alone for early pregnancy loss. STUDY DESIGN We performed a planned secondary analysis of a randomized trial comparing mifepristone-misoprostol with misoprostol alone for management of early pregnancy loss. The published prediction model for treatment success of single-dose misoprostol administered vaginally included the following variables: active bleeding, type of early pregnancy loss (anembryonic pregnancy or embryonic and/or fetal demise), parity, gestational age, and treatment site; previous significant predictors were vaginal bleeding within the past 24 hours and parity of 0 or 1 vs >1. To determine if these characteristics predicted differential proportions of patients with treatment success or failure, we performed bivariate analyses; given the small proportion of treatment failures in the combined treatment arm, both arms were combined for analysis. Thereafter, we performed a logistic regression analysis to assess the effect of these predictors collectively in each of the 2 treatment groups separately as well as in the full cohort as a proxy for the combined treatment arm. Finally, by using receiver operating characteristic curves, we tested the ability of these predictors in association with misoprostol treatment success to discriminate between treatment success and treatment failure. To quantify the ability of the score to discriminate between treatment success and treatment failure in each treatment arm as well as in the entire cohort, we calculated the area under the curve. Using multivariable logistic regression, we then assessed our study population for other predictors of treatment success in both treatment groups, with and without mifepristone pretreatment. RESULTS Overall, 297 evaluable participants were included in the primary study, with 148 in the mifepristone-misoprostol combined treatment group and 149 in the misoprostol-alone treatment group. Among patients who had vaginal bleeding at the time of treatment, 15 of 17 (88%) in the mifepristone-misoprostol combined treatment group and 12 of 17 (71%) in the misoprostol-alone treatment group experienced expulsion of pregnancy tissue. Among patients with a parity of 0 or 1, 94 of 108 (87%) in the mifepristone-misoprostol treatment group and 66 of 95 (69%) in the misoprostol-alone treatment group experienced expulsion of pregnancy tissue. These clinical characteristics did not predict treatment success in the combined cohort alone (area under the curve=0.56; 95% confidence interval, 0.48-0.64). No other baseline clinical factors predicted treatment success in the misoprostol-alone treatment arm or mifepristone pretreatment arm. In the full cohort, the significant predictors of treatment success were pretreatment with mifepristone (adjusted odds ratio=2.51; 95% confidence interval, 1.43-4.43) and smoking (adjusted odds ratio=2.15; 95% confidence interval, 1.03-4.49). CONCLUSION No baseline clinical factors predicted treatment success in women receiving medical management with misoprostol for early pregnancy loss. Adding mifepristone to the medical management regimen of early pregnancy loss improved treatment success; thus, mifepristone treatment should be considered for management of early pregnancy loss regardless of baseline clinical factors.
Collapse
|
29
|
Flynn AN, Galvao R, McAllister A, Sonalkar S. EXPLORING TECHNOLOGY-BASED INTERVENTIONS TO IMPROVE ORAL CONTRACEPTIVE PILL ADHERENCE: A CROSS-SECTIONAL SURVEY. Fertil Steril 2020. [DOI: 10.1016/j.fertnstert.2020.08.495] [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: 10/23/2022]
|
30
|
Abstract
Telemedicine has the potential to increase access to family planning. The most common application involved the use of text message reminders and mobile apps. Text messaging increased knowledge in a variety of settings, but had no effect on contraceptive uptake and use. Two randomized studies found that text messaging improved continuation of oral contraceptives and injectables. Telemedicine provision of medication abortion included both clinic-to-clinic and direct-to-patient models of care. Telemedicine provision of medication abortion has been found to be equally safe and effective as in-person provision. Some measures of satisfaction are higher with telemedicine. Telemedicine may improve access to early abortion.
Collapse
Affiliation(s)
- Terri-Ann Thompson
- Ibis Reproductive Health, 2067 Massachusetts Avenue, Suite 320, Cambridge, MA 02140, USA.
| | - Sarita Sonalkar
- Department of Obstetrics and Gynecology, University of Pennsylvania, 1000 Courtyard, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Jessica L Butler
- The American College of Obstetricians and Gynecologists, 409 12th Street, Southwest, PO Box 96920, Washington, DC 20090-6920, USA
| | - Daniel Grossman
- Department of Obstetrics, Gynecology and Reproductive Sciences, Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, University of California San Francisco, 1330 Broadway, Suite 1100, Oakland, CA 94612, USA. https://twitter.com/DrDGrossman
| |
Collapse
|
31
|
Shorter JM, Schreiber CA, Sonalkar S. Recent Advances in the Medical Management of Early Pregnancy Loss. Curr Obstet Gynecol Rep 2020. [DOI: 10.1007/s13669-020-00282-0] [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: 12/01/2022]
|
32
|
Anand P, McAllister A, Hunter T, Schreiber CA, Koelper N, Sonalkar S. A simulated patient study to assess referrals to abortion care by student health centers in Pennsylvania. Contraception 2020; 102:23-29. [PMID: 32114006 DOI: 10.1016/j.contraception.2020.02.009] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 02/18/2020] [Accepted: 02/19/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine college health centers' referral patterns for students seeking induced abortion. STUDY DESIGN We conducted a cross-sectional simulated patient study at 4-year colleges in Pennsylvania between June 2017 and May 2018. A researcher posing as a student seeking abortion referral contacted student health centers twice during the course of the study using a structured script, once as a minor (under 18 years), and once as an adult. The primary outcome was "direct referral", defined as a referral to an abortion provider. We measured proportions of student health centers who provided no referral, "indirect referral" (referral to a non-specific provider), and "inappropriate referral" (referral to a non-abortion provider). We analyzed the relationship between the proportion of direct referrals and minor status of the caller as well as college characteristics (religious affiliation, location, student body mean income, and size). We included variables found to be significant as covariates in a generalized linear model that accounted for the cluster of multiple calls to each institution. RESULTS We attempted contact with 115 institutions, once as a minor and once as an adult, resulting in 202 successful contacts. Direct referral was the most common outcome (49.5%), followed by inappropriate referral (33.7%) and no referral (21.8%). The proportion of direct referrals given to minors was similar when compared to adults (48.0% vs 52.0%, OR 0.82, 95% CI 0.47-1.42). Religiously affiliated institutions were less likely to provide a direct referral than non-religiously affiliated schools (aOR 0.47, 95% CI 0.30-0.75). With each increase in students' household income tertile, health centers were more likely to provide a direct referral (aOR 1.22, 95% CI 1.05-1.42). CONCLUSIONS Half of college student health centers in Pennsylvania do not provide direct abortion referrals, and many provide inappropriate referrals. Student health centers at religiously affiliated institutions and those with poorer students are less likely to provide direct abortion referrals. IMPLICATIONS Student health providers should inform themselves about fake health clinics and local abortion providers. Colleges should train staff, create accurate resources and define clear policies around referral. Professional and policymaking organizations should affirm the duty of all college health centers, regardless of religious affiliation, to provide abortion referrals.
Collapse
Affiliation(s)
- Priyanka Anand
- Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA.
| | - Arden McAllister
- Perelman School of Medicine, University of Pennsylvania, Division of Family Planning, Department of Obstetrics and Gynecology, University of Pennsylvania Health System, 3400 Spruce Street, 1000 Courtyard, Philadelphia, PA 19104, USA
| | - Tegan Hunter
- University of Miami Miller School of Medicine, 1600 NW 10th Ave #1140, Miami, FL 33136, USA
| | - Courtney A Schreiber
- Perelman School of Medicine, University of Pennsylvania, Division of Family Planning, Department of Obstetrics and Gynecology, University of Pennsylvania Health System, 3400 Spruce Street, 1000 Courtyard, Philadelphia, PA 19104, USA
| | - Nathanael Koelper
- Perelman School of Medicine, University of Pennsylvania, Division of Family Planning, Department of Obstetrics and Gynecology, University of Pennsylvania Health System, 3400 Spruce Street, 1000 Courtyard, Philadelphia, PA 19104, USA
| | - Sarita Sonalkar
- Perelman School of Medicine, University of Pennsylvania, Division of Family Planning, Department of Obstetrics and Gynecology, University of Pennsylvania Health System, 3400 Spruce Street, 1000 Courtyard, Philadelphia, PA 19104, USA
| |
Collapse
|
33
|
Nagendra D, Koelper N, Loza-Avalos SE, Sonalkar S, Chen M, Atrio J, Schreiber CA, Harvie HS. Cost-effectiveness of Mifepristone Pretreatment for the Medical Management of Nonviable Early Pregnancy: Secondary Analysis of a Randomized Clinical Trial. JAMA Netw Open 2020; 3:e201594. [PMID: 32215633 PMCID: PMC7439768 DOI: 10.1001/jamanetworkopen.2020.1594] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [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: 11/14/2022] Open
Abstract
IMPORTANCE Early pregnancy loss (EPL) is the most common complication of pregnancy. A multicenter randomized clinical trial compared 2 strategies for medical management and found that mifepristone pretreatment is 25% more effective than the standard of care, misoprostol alone. The cost of mifepristone may be a barrier to implementation of the regimen. OBJECTIVE To assess the cost-effectiveness of medical management of EPL with mifepristone pretreatment plus misoprostol vs misoprostol alone in the United States. DESIGN, SETTING, AND PARTICIPANTS This preplanned. prospective economic evaluation was performed concurrently with a randomized clinical trial in 3 US sites from May 1, 2014, through April 30, 2017. Participants included 300 women with anembryonic gestation or embryonic or fetal demise. Cost-effectiveness was computed from the health care sector and societal perspectives, with a 30-day time horizon. Data were analyzed from July 1, 2018, to July 3, 2019. INTERVENTIONS Mifepristone pretreatment plus misoprostol administration vs misoprostol alone. MAIN OUTCOMES AND MEASURES Costs in 2018 US dollars, effectiveness in quality-adjusted life-years (QALYs), and treatment efficacy. Incremental cost-effectiveness ratios (ICERs) of mifepristone and misoprostol vs misoprostol alone were calculated, and cost-effectiveness acceptability curves were generated. RESULTS Among the 300 women included in the randomized clinical trial (mean [SD] age, 30.4 [6.2] years), mean costs were similar for groups receiving mifepristone pretreatment and misoprostol alone from the health care sector perspective ($696.75 [95% CI, $591.88-$801.62] vs $690.88 [95% CI, $562.38-$819.38]; P = .94) and the societal perspective ($3846.30 [95% CI, $2783.01-$4909.58] vs $4845.62 [95% CI, $3186.84-$6504.41]; P = .32). The mifepristone pretreatment group had higher QALYs (0.0820 [95% CI, 0.0815-0.0825] vs 0.0806 [95% CI, 0.0800-0.0812]; P = .001) and a higher completion rate after first treatment (83.8% vs 67.1%; P < .001) than the group receiving misoprostol alone. From the health care sector perspective, mifepristone pretreatment was cost-effective relative to misoprostol alone with an ICER of $4225.43 (95% CI, -$195 053.30 to $367 625.10) per QALY gained. From the societal perspective, mifepristone pretreatment dominated misoprostol alone (95% CI, -$5 111 629 to $1 801 384). The probabilities that mifepristone pretreatment was cost-effective compared with misoprostol alone at a willingness-to-pay of $150 000 per QALY gained from the health care sector and societal perspectives were approximately 90% and 80%, respectively. CONCLUSIONS AND RELEVANCE This study found that medical management of EPL with mifepristone pretreatment was cost-effective when compared with misoprostol alone. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02012491.
Collapse
Affiliation(s)
- Divyah Nagendra
- Department of Obstetrics and Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Nathanael Koelper
- Department of Obstetrics and Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Sandra E Loza-Avalos
- Department of Obstetrics and Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Sarita Sonalkar
- Department of Obstetrics and Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Melissa Chen
- Department of Obstetrics and Gynecology, University of California, Davis, Sacramento
| | - Jessica Atrio
- Department of Obstetrics and Gynecology, Montefiore Hospital, Albert Einstein College of Medicine, Bronx, New York
| | - Courtney A Schreiber
- Department of Obstetrics and Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Heidi S Harvie
- Department of Obstetrics and Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia
| |
Collapse
|
34
|
Hunter TA, Sonalkar S, Schreiber CA, Perriera LK, Sammel MD, Akers AY. Anticipated Pain During Intrauterine Device Insertion. J Pediatr Adolesc Gynecol 2020; 33:27-32. [PMID: 31563628 PMCID: PMC6980875 DOI: 10.1016/j.jpag.2019.09.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 09/15/2019] [Accepted: 09/20/2019] [Indexed: 11/21/2022]
Abstract
STUDY OBJECTIVE To identify predictors of anticipated pain with intrauterine device (IUD) insertion in adolescents and young women. DESIGN We performed linear regression to identify demographic, sexual/gynecologic history, and mood covariates associated with anticipated pain using a visual analogue scale pain score collected as part of a single-blind randomized trial of women who received a 13.5-mg levonorgestrel IUD. SETTING Three academic family planning clinics in Philadelphia Pennsylvania. PARTICIPANTS Ninety-three adolescents and young adult women aged 14-22 years. INTERVENTION Participants received either a 1% lidocaine or sham paracervical block. MAIN OUTCOME MEASURES Anticipated pain measured using a visual analogue scale before and perceived pain at 6 time points during the IUD insertion procedure. RESULTS Black or African American participants had a median anticipated pain score of 68 (interquartile range [IQR], 52-83), White participants had a median anticipated pain of 51 (IQR, 35-68), whereas participants of other races had a median anticipated pain score of 64 (IQR, 36-73); P = .012. In multivariate analysis, race was the only covariate that significantly predicted anticipated pain at IUD insertion. Women with anticipated pain scores above the median had significantly higher perceived pain during all timepoints of the IUD insertion procedure. CONCLUSION Increased anticipated pain is associated with increased perceived pain with IUD insertion. Black adolescent women experience greater anticipated pain with IUD insertion. This population might benefit from counseling and clinical measures to reduce this barrier to IUD use.
Collapse
Affiliation(s)
- Tegan A Hunter
- University of Miami Miller School of Medicine, Miami, Florida.
| | - Sarita Sonalkar
- Department of Obstetrics and Gynecology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Courtney A Schreiber
- Department of Obstetrics and Gynecology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Lisa K Perriera
- Department of Obstetrics and Gynecology, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Mary D Sammel
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Aletha Y Akers
- Division of Adolescent Medicine, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| |
Collapse
|
35
|
Paris AE, Vragovic O, Sonalkar S, Finneseth M, Borgatta L. Mifepristone and misoprostol compared to osmotic dilators for cervical preparation prior to surgical abortion at 15-18 weeks' gestation: a randomised controlled non-inferiority trial. BMJ Sex Reprod Health 2019; 46:bmjsrh-2019-200367. [PMID: 31754065 DOI: 10.1136/bmjsrh-2019-200367] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 11/04/2019] [Accepted: 11/06/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE Cervical preparation is recommended prior to second-trimester surgical abortion. Osmotic dilators are an effective means to prepare the cervix, but require an additional procedure and may cause discomfort. We compared cervical preparation with mifepristone and misoprostol to preparation with osmotic dilators. STUDY DESIGN A randomised, controlled, non-inferiority trial was performed to compare cervical preparation with mifepristone and misoprostol to preparation with osmotic dilators in women undergoing surgical abortion between 15 and 18 weeks gestation. The medication group (n=29) received mifepristone 200 mg orally 24 hours prior to uterine evacuation and misoprostol 400 μg buccally 2 hours before the procedure. The dilator group (n=20) underwent osmotic dilator insertion 24 hours prior to the procedure. The primary outcome was total procedure time, from insertion to removal of the speculum. Secondary outcomes included operative time (from intrauterine instrumentation to speculum removal), initial cervical dilation, nausea, pain, ease of procedure, and whether participants would choose the same modality in the future. RESULTS For mean total procedure time, medication preparation (14.0 min, 95% CI 12.0-16.1) was not inferior to dilators (14.3 min, 95% CI 11.7 to 16.8, p<0.001). Mean operative time and ease of procedure were also similar between groups. More women in the medication group than the dilator group would prefer to use the same method in the future (86% vs 30%, p=0.003). CONCLUSION Prior to surgical abortion at 15-18 weeks, use of mifepristone and misoprostol did not result in longer procedure times than overnight osmotic dilators. TRIAL REGISTRATION NUMBER NCT01462.
Collapse
Affiliation(s)
- Amy E Paris
- Obstetrics and Gynecology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
- Dartmouth College Geisel School of Medicine, Hanover, New Hampshire, USA
| | | | - Sarita Sonalkar
- Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Molly Finneseth
- Obstetrics and Gynecology, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Lynn Borgatta
- Obstetrics and Gynecology, Boston University School of Medicine, Boston, Massachusetts, USA
| |
Collapse
|
36
|
Sonalkar S, Chavez V, McClusky J, Hunter TA, Mollen CJ. Gynecologic Care for Women With Physical Disabilities: A Qualitative Study of Patients and Providers. Womens Health Issues 2019; 30:136-141. [PMID: 31722816 PMCID: PMC10093685 DOI: 10.1016/j.whi.2019.10.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 09/08/2019] [Accepted: 10/07/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND Women with physical disabilities have unmet gynecologic care needs, including disparities in cancer screening and contraceptive care, when compared with women without physical disabilities. Our objective was to qualitatively assess provider and patient perspectives regarding barriers to gynecologic health care for women with physical disabilities. METHODS We used purposive sampling to recruit women with physical disabilities and gynecology providers who had experience caring for this population at two university hospitals. Patient and provider participants completed in-depth, semistructured interviews investigating their experiences with and barriers to receiving or providing gynecologic care. Transcripts were systematically analyzed by reviewing assigned codes and performing thematic analysis. We planned a sample size of at least 20 patient and provider participants to allow for saturation of thematic content. RESULTS We interviewed 29 women with physical disabilities and 20 providers. Important themes for providers and patients centered around adequate time spent during appointments, challenges with the gynecologic examination, inadequate facilities, clinical space limitations, and lack of formal provider and staff training in caring for this population. CONCLUSIONS Providers were motivated to provide quality care for women with disabilities, but encountered systems and training barriers. Patients and providers had concordant impressions of barriers that influenced equitable and patient-centered care, with structural barriers, including a lack of accessible space, closely related to perceptions of health care inequity between women with and without physical disabilities.
Collapse
Affiliation(s)
- Sarita Sonalkar
- Department of Obstetrics and Gynecology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania; Department of Obstetrics and Gynecology, Boston Medical Center, Boston, Massachusetts.
| | - Veronica Chavez
- Department of Obstetrics and Gynecology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania; Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania
| | - Jessica McClusky
- Department of Obstetrics and Gynecology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania; Department of Obstetrics and Gynecology, Boston Medical Center, Boston, Massachusetts; University of Pennsylvania, School of Nursing, Philadelphia, Pennsylvania
| | - Tegan A Hunter
- Division of Emergency Medicine, University of Miami Miller School of Medicine, Miami, Florida
| | - Cynthia J Mollen
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| |
Collapse
|
37
|
Sonalkar S, Schreiber CA. It is cost effective to improve the standard of care for women experiencing miscarriage. The Lancet Global Health 2019; 7:e1164-e1165. [DOI: 10.1016/s2214-109x(19)30314-6] [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: 07/08/2019] [Accepted: 07/13/2019] [Indexed: 11/29/2022] Open
|
38
|
Sonalkar S, Koelper NC, Creinin MD, Atrio JM, Sammel MD, Schreiber CA. Management of early pregnancy loss with mifepristone and misoprostol: clinical predictors of success from a randomized trial. Fertil Steril 2019. [DOI: 10.1016/j.fertnstert.2019.07.1146] [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: 10/25/2022]
|
39
|
Deshpande NA, Labora A, Sammel MD, Schreiber CA, Sonalkar S. Relationship between body mass index and operative time in women receiving immediate postpartum tubal ligation. Contraception 2019; 100:106-110. [PMID: 31082395 PMCID: PMC6849505 DOI: 10.1016/j.contraception.2019.05.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [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: 01/23/2019] [Revised: 04/28/2019] [Accepted: 05/01/2019] [Indexed: 12/26/2022]
Abstract
OBJECTIVES The aim of the study was to (1) assess the relationship between body mass index (BMI) and operative time during immediate postpartum tubal ligation procedures and to (2) determine whether operative time is non-inferior in women with BMI ≥30 versus women with BMI <30 and in women with BMI ≥40 versus women with BMI <40. STUDY DESIGN We conducted a retrospective cohort study of women who received immediate postpartum tubal ligations following vaginal delivery from 2013 to 2017 at a university hospital. We abstracted demographic information, patient and procedural characteristics, and clinical outcomes. We assessed the relationship between BMI and operative time via linear regression. We also conducted non-inferiority analysis to determine whether the mean operative time in women with BMI ≥30 was non-inferior to the mean operative time in women with BMI <30, within a non-inferiority margin of 10 min. We compared intraoperative and postoperative complications in the two groups. RESULTS A total of 279 women were included for analysis, among whom N=79 (28%) had a BMI of 25-29.9 and N=171 (61%) had a BMI ≥30. Demographic characteristics were similar in both groups. We found that operative time increased by 35 s for each one-point increase in BMI (p<.01). Although mean operative time was 46.1 min (n=171; 95% CI 43.7, 48.6 min) for women with BMI ≥30 and 40.6 min (n=108; 95% CI 37.9 min, 43.4 min) for women with BMI <30, (p<.01), it was non-inferior within a 10-min margin. There was no difference in rates of intraoperative or postoperative complications, incision length, total anesthesia time, and median length of stay between women with BMI ≥30 and BMI <30. CONCLUSION There is a small increase in postpartum tubal ligation operative time with increasing BMI. However, among women who received immediate postpartum tubal ligations at our institution, women with BMI ≥30 versus BMI <30 had operative times that were non-inferior within a 10-min margin. IMPLICATIONS While increasing body mass index slightly increases the operative time for immediate postpartum tubal ligations, this increase in time does not appear to be clinically significant.
Collapse
Affiliation(s)
- Neha A Deshpande
- Hospital of the University of Pennsylvania, Department of Obstetrics & Gynecology, Philadelphia, PA.
| | - Amanda Labora
- Hospital of the University of Pennsylvania, Department of Obstetrics & Gynecology, Philadelphia, PA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Mary D Sammel
- Hospital of the University of Pennsylvania, Department of Obstetrics & Gynecology, Philadelphia, PA; Department of Biostatistics, Epidemiology & Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Courtney A Schreiber
- Hospital of the University of Pennsylvania, Department of Obstetrics & Gynecology, Philadelphia, PA
| | - Sarita Sonalkar
- Hospital of the University of Pennsylvania, Department of Obstetrics & Gynecology, Philadelphia, PA
| |
Collapse
|
40
|
Koenig AF, Borrero S, Zhao X, Callegari L, Mor MK, Sonalkar S. Factors associated with long-acting reversible contraception use among women Veterans in the ECUUN study. Contraception 2019; 100:234-240. [PMID: 31152697 DOI: 10.1016/j.contraception.2019.05.010] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 05/19/2019] [Accepted: 05/20/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The objective of this study is to understand patient-, provider- and system-level factors associated with long-acting reversible contraception (LARC) use among women Veterans and with receipt of LARC methods within the Veterans Affairs (VA) system. STUDY DESIGN We analyzed data from a national telephone-based survey of 2302 women ages 18-44 receiving primary care in VA. Multivariable regression was used to examine adjusted associations of participant-reported patient-, provider- and facility-level factors with LARC use and within-VA receipt of LARC among women Veterans. RESULTS Among 987 women Veterans at risk of unintended pregnancy, 294 (30%) reported using LARC, 65% of whom had received their method within VA. Higher LARC use was observed among women who were multiparous vs. nulliparous [adjusted odds ratio (aOR)=1.52; 95% confidence interval (CI)=1.04-2.22] and did not desire future pregnancies (aOR=1.88; 95% CI=1.31-2.68). Although overall LARC uptake was not associated with any provider- or facility-level factors, receipt of these methods within VA was associated with receiving both general and gender-specific health care by a single provider (aOR=2.81; 95% CI=1.20-6.61) and with receiving care within a women's health clinic (aOR=2.54; 95% CI=1.17-5.50). CONCLUSIONS While patient-level factors were more strongly correlated with use of LARC, provider- and system-level factors influence whether women received these methods within VA. IMPLICATIONS This study of patient-, provider- and system-level correlates of LARC use in VA, the country's largest integrated healthcare system, highlights that women Veterans share similar patient-level factors associated with LARC use as the general population and that continuity with providers and comprehensive women's health services can facilitate LARC access.
Collapse
Affiliation(s)
- Angela F Koenig
- Department of Obstetrics and Gynecology, The Hospital of the University of Pennsylvania.
| | - Sonya Borrero
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System; Center for Research on Health Care, University of Pittsburgh School of Medicine
| | - Xinhua Zhao
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System
| | - Lisa Callegari
- VA Health Services Research and Development Center of Innovation for Veteran-Centered and Value Driven Care, VA Puget Sound Healthcare System; Department of Obstetrics and Gynecology, University of Washington School of Medicine
| | - Maria K Mor
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System
| | - Sarita Sonalkar
- Department of Obstetrics and Gynecology, The Hospital of the University of Pennsylvania
| |
Collapse
|
41
|
O'Flynn O'Brien KL, Akers AY, Perriera LK, Schreiber CA, Garcia-Espana JF, Sonalkar S. Intrauterine Device Insertion Procedure Duration in Adolescent and Young Adult Women. J Pediatr Adolesc Gynecol 2019; 32:312-315. [PMID: 30633980 PMCID: PMC6570557 DOI: 10.1016/j.jpag.2019.01.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [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: 10/19/2018] [Revised: 12/20/2018] [Accepted: 01/01/2019] [Indexed: 10/27/2022]
Abstract
STUDY OBJECTIVE Intrauterine device (IUD) utilization in the United States is low among adolescent and young adult women. Longer procedure duration has been proposed as one potential barrier to IUD insertion in this population. We hypothesized that procedure duration would be longer in adolescents compared to young adult women. DESIGN, SETTING, AND PARTICIPANTS This study was a secondary analysis of a randomized clinical trial comparing the effectiveness of a lidocaine vs sham paracervical nerve block for pain control during levonorgestrel 13.5 mg IUD insertion. Adolescent and young adult women ages 14-22 years were recruited from 3 outpatient academic sites in Philadelphia, Pennsylvania. INTERVENTIONS AND MAIN OUTCOME MEASURES Pain scores were recorded at 7 steps during the procedure from speculum insertion through removal. Time stamps associated with each step were used to calculate the overall procedure duration. Cumulative IUD insertion procedure duration was estimated using the Kaplan-Meier method. RESULTS Ninety-five women enrolled. Nineteen (19/95, 20%) were ages 14-17 and 76 (76/95, 80%) were ages 18-22 years. The median procedure duration (seconds ± interquartile range) was longer for adolescents than for young adults (555 ± 428 seconds vs 383 ± 196 seconds; P = .008). After adjusting for study site, the difference in expected median procedure duration between age groups was not significant (P = .3832). CONCLUSION The difference in duration of IUD insertion procedures in adolescent and young adult women is not clinically or statistically significant. Providers should not withhold IUDs from appropriate adolescent and young adult women on the basis of age alone.
Collapse
Affiliation(s)
- Katherine L O'Flynn O'Brien
- Department of Obstetrics and Gynecology, The Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Aletha Y Akers
- Craig Dalsimer Division of Adolescent Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Lisa K Perriera
- Department of Obstetrics and Gynecology, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Courtney A Schreiber
- Department of Obstetrics and Gynecology, The Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Sarita Sonalkar
- Department of Obstetrics and Gynecology, The Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| |
Collapse
|
42
|
Frarey A, Schreiber C, McAllister A, Shaber A, Sonalkar S, Sammel MD, Long JA. Pathways to Abortion at a Tertiary Care Hospital: Examining Obesity and Delays. Perspect Sex Reprod Health 2019; 51:35-41. [PMID: 30645011 DOI: 10.1363/psrh.12086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 08/22/2018] [Accepted: 09/18/2018] [Indexed: 06/09/2023]
Abstract
CONTEXT Advancing gestational age can increase the cost of an abortion and is a significant risk factor for complications. While obesity is not associated with increased risks, anecdotal evidence suggests that obese women seeking services at freestanding abortion clinics are often referred for hospital-based care, which can lead to delays. METHODS In 2016, a cross-sectional survey collected data on the experiences of 201 women who had obtained abortions at a hospital-based clinic in Philadelphia; rates of medical complications were determined from hospital records. Multivariable logistic regression analysis was used to assess if obesity was associated with whether patients had been referred from freestanding abortion clinics or reported other paths to care. Differences in wait time and up-front out-of-pocket costs were examined by women's referral status. RESULTS No difference in rates of abortion complications was found between patient groups. Women who were severely obese (body mass index of at least 40 kg/m2 ) were more likely than normal-weight individuals to have been referred from a freestanding abortion clinic (odds ratio, 7.5). The median wait time to get an abortion was 28 days for referred patients and 12 days for others. Multivariable analysis confirmed that referred patients waited twice as long as other patients (rate ratio, 2.0) and paid 66% more in up-front costs. CONCLUSIONS Future research is needed to determine whether obese women seeking abortions are being referred despite evidence that they do not require hospital-based care. If obese women are suffering delays because of referral, strategies to help overcome delay should also be explored.
Collapse
Affiliation(s)
- Alhambra Frarey
- Assistant Professor, Department of Obstetrics and Gynecology, The University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Courtney Schreiber
- Associate Professor, Department of Obstetrics and Gynecology, The University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Arden McAllister
- Research Program Manager, Department of Obstetrics and Gynecology, The University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Allison Shaber
- Medical Student, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia
| | - Sarita Sonalkar
- Assistant Professor, Department of Obstetrics and Gynecology, The University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Mary D Sammel
- Professor, Center for Clinical Epidemiology and Biostatistics, The University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Judith A Long
- Professor, Corporal Michael J. Crezenz VA Center for Health Equity Research and Promotion, and Department of Medicine, The University of Pennsylvania Perelman School of Medicine, Philadelphia
| |
Collapse
|
43
|
Sonalkar S, Hunter T, Gurney EP, McAllister A, Schreiber C. A Decision Analysis Model of 1-Year Effectiveness of Intended Postplacental Compared With Intended Delayed Postpartum Intrauterine Device Insertion. Obstet Gynecol 2018; 132:1211-1221. [PMID: 30303909 PMCID: PMC6328318 DOI: 10.1097/aog.0000000000002926] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [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] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To compare, using decision analysis methodology, the 1-year probability of pregnancy after intended postplacental intrauterine device (IUD) insertion with intended delayed insertion at an outpatient postpartum visit (delayed postpartum placement). METHODS We developed an evidence-based decision model with the primary outcome of 1-year probability of pregnancy. We compared 1-year probability of pregnancy after intended postplacental or intended delayed postpartum IUD placement. We obtained estimates from the literature for the proportions of the following: mode of delivery, successful IUD placement, IUD type, postpartum visit attendance, IUD expulsion, IUD discontinuation, and contraceptive use, choice, and efficacy after IUD discontinuation. We performed sensitivity analyses and a Monte Carlo simulation to account for variations in proportion estimates. RESULTS One-year probabilities of pregnancy among a theoretical cohort of 2,500,000 women intending to receive a postplacental IUD after vaginal birth and 1,250,000 women intending to receive a postplacental IUD after cesarean birth were 17.3% and 11.2%, respectively; the 1-year probability of pregnancy among a theoretical cohort of 2,500,000 women intending to receive a delayed postpartum IUD was 24.6%. For delayed postpartum IUD placement to have effectiveness equal to postplacental placement, 91.4% of women delivering vaginally and 99.7% of women delivering by cesarean would need to attend postpartum care. Once placed, the effectiveness of postplacental IUDs was lower than that of delayed postpartum IUDs: 1-year probabilities of pregnancy after IUD placement at a vaginal birth, cesarean birth, and an outpatient postpartum visit were 15.4%, 6.6%, and 3.9%, respectively. CONCLUSION After accounting for factors that affect successful IUD placement and retention, this decision model indicates that intended postplacental IUD insertion results in a lower 1-year probability of pregnancy as compared with intended delayed postpartum IUD insertion.
Collapse
Affiliation(s)
- Sarita Sonalkar
- University of Pennsylvania Perelman School of Medicine, Department of Obstetrics and Gynecology
| | | | | | - Arden McAllister
- University of Pennsylvania Perelman School of Medicine, Department of Obstetrics and Gynecology
| | - Courtney Schreiber
- University of Pennsylvania Perelman School of Medicine, Department of Obstetrics and Gynecology
| |
Collapse
|
44
|
Deshpande N, Labora A, Sammel M, Schreiber CA, Sonalkar S. Operative time in obese and nonobese women receiving postpartum tubal sterilization. Contraception 2018. [DOI: 10.1016/j.contraception.2018.07.126] [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: 10/28/2022]
|
45
|
Gurney EP, Sonalkar S, McAllister A, Sammel MD, Schreiber CA. Six-month expulsion of postplacental copper intrauterine devices placed after vaginal delivery. Am J Obstet Gynecol 2018; 219:183.e1-183.e9. [PMID: 29870737 DOI: 10.1016/j.ajog.2018.05.032] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Revised: 05/18/2018] [Accepted: 05/24/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND Immediate placement of an intrauterine device after vaginal delivery is safe and convenient, but longitudinal data describing clinical outcomes have been limited. OBJECTIVE We sought to determine the proportion of TCu380A (copper) intrauterine devices expelled, partially expelled, malpositioned, and retained, as well as contraceptive use by 6 months postpartum, and determine risk factors for expulsion and partial expulsion. STUDY DESIGN In this prospective, observational study, women who received a postplacental TCu380A intrauterine device at vaginal delivery were enrolled postpartum. Participants returned for clinical follow-up at 6 weeks, and for a research visit with a pelvic exam and ultrasound at 6 months. We recorded intrauterine device outcomes and 6-month contraceptive use. Partial expulsion was defined as an intrauterine device protruding from the external cervical os, or a transvaginal ultrasound showing the distal end of the intrauterine device below the internal os of the cervix. Multinomial logistic regression models identified risk factors associated with expulsion and partial expulsion by 6 months. The area under the receiver operating characteristics curve was used to assess the ability of a string check to predict the correct placement of a postplacental intrauterine device. The primary outcome was the proportion of intrauterine devices expelled at 6 months. RESULTS We enrolled 200 women. Of 162 participants with follow-up data at 6 months, 13 (8.0%; 95% confidence interval, 4.7-13.4%) experienced complete expulsion and 26 (16.0%; 95% confidence interval, 11.1-22.6%) partial expulsion. Of 25 malpositioned intrauterine devices (15.4%; 95% confidence interval, 10.2-21.9%), 14 were not at the fundus (8.6%; 95% confidence interval, 5.2-14.1%) and 11 were rotated within the uterus (6.8%; 95% confidence interval, 3.8-11.9%). Multinomial logistic regression modeling indicated that higher parity (odds ratio, 2.05; 95% confidence interval, 1.21-3.50; P = .008) was associated with expulsion. Provider specialty (obstetrics vs family medicine; odds ratio, 5.31; 95% confidence interval, 1.20-23.59; P = .03) and gestational weight gain (normal vs excess; odds ratio, 9.12; 95% confidence interval, 1.90-43.82; P = .004) were associated with partial expulsion. Long-acting reversible contraceptive method use at 6 months was 80.9% (95% confidence interval, 74.0-86.6%). At 6 weeks postpartum, 35 of 149 (23.5%; 95% confidence interval, 16.9-31.1%) participants had no intrauterine device strings visible. Sensitivity of a string check to detect an incorrectly positioned intrauterine device was 36.2%, and specificity of the string check to predict a correctly positioned intrauterine device was 84.5%. This corresponds to an area under the receiver operating characteristics curve of 0.5. CONCLUSION This prospective assessment of postplacental TCu380A intrauterine device placement, with ultrasound to confirm device position, finds a complete intrauterine device expulsion proportion of 8.0% at 6 months. The association of increasing parity with expulsion is consistent with prior research. The clinical significance of covariates associated with partial expulsion (provider specialty and gestational weight gain) is unclear. Due to the observational study design, any associations cannot imply causality. The proportion of partially expelled and malpositioned intrauterine devices was high, and the area under the receiver operating characteristics curve of 0.5 indicates that a string check is a poor test for assessing device position. Women considering a postplacental intrauterine device should be counseled about the risk of position abnormalities, as well as the possibility of nonvisible strings, which may complicate clinical follow-up. The clinical significance of intrauterine device position abnormalities is unknown; future research should evaluate the influence of malposition and partial expulsion on contraceptive effectiveness and side effects.
Collapse
|
46
|
Abstract
BACKGROUND Medical management of early pregnancy loss is an alternative to uterine aspiration, but standard medical treatment with misoprostol commonly results in treatment failure. We compared the efficacy and safety of pretreatment with mifepristone followed by treatment with misoprostol with the efficacy and safety of misoprostol use alone for the management of early pregnancy loss. METHODS We randomly assigned 300 women who had an anembryonic gestation or in whom embryonic or fetal death was confirmed to receive pretreatment with 200 mg of mifepristone, administered orally, followed by 800 μg of misoprostol, administered vaginally (mifepristone-pretreatment group), or 800 μg of misoprostol alone, administered vaginally (misoprostol-alone group). Participants returned 1 to 4 days after misoprostol use for evaluation, including ultrasound examination, by an investigator who was unaware of the treatment-group assignments. Women in whom the gestational sac was not expelled were offered expectant management, a second dose of misoprostol, or uterine aspiration. We followed all participants for 30 days after randomization. Our primary outcome was gestational sac expulsion with one dose of misoprostol by the first follow-up visit and no additional intervention within 30 days after treatment. RESULTS Complete expulsion after one dose of misoprostol occurred in 124 of 148 women (83.8%; 95% confidence interval [CI], 76.8 to 89.3) in the mifepristone-pretreatment group and in 100 of 149 women (67.1%; 95% CI, 59.0 to 74.6) in the misoprostol-alone group (relative risk, 1.25; 95% CI, 1.09 to 1.43). Uterine aspiration was performed less frequently in the mifepristone-pretreatment group than in the misoprostol-alone group (8.8% vs. 23.5%; relative risk, 0.37; 95% CI, 0.21 to 0.68). Bleeding that resulted in blood transfusion occurred in 2.0% of the women in the mifepristone-pretreatment group and in 0.7% of the women in the misoprostol-alone group (P=0.31); pelvic infection was diagnosed in 1.3% of the women in each group. CONCLUSIONS Pretreatment with mifepristone followed by treatment with misoprostol resulted in a higher likelihood of successful management of first-trimester pregnancy loss than treatment with misoprostol alone. (Funded by the National Institute of Child Health and Human Development; PreFaiR ClinicalTrials.gov number, NCT02012491 .).
Collapse
MESH Headings
- Abortifacient Agents, Nonsteroidal/administration & dosage
- Abortifacient Agents, Nonsteroidal/adverse effects
- Abortifacient Agents, Steroidal/administration & dosage
- Abortifacient Agents, Steroidal/adverse effects
- Abortion, Spontaneous/diagnostic imaging
- Abortion, Spontaneous/drug therapy
- Administration, Intravaginal
- Administration, Oral
- Adult
- Drug Therapy, Combination
- Embryo, Mammalian
- Female
- Fetal Death
- Gestational Sac/diagnostic imaging
- Hemorrhage/chemically induced
- Humans
- Mifepristone/administration & dosage
- Mifepristone/adverse effects
- Misoprostol/administration & dosage
- Misoprostol/adverse effects
- Pregnancy
- Pregnancy Trimester, First
- Ultrasonography
Collapse
Affiliation(s)
- Courtney A Schreiber
- From the Pregnancy Early Access Center (PEACE), Division of Family Planning (C.A.S., S.S.), Department of Obstetrics and Gynecology (C.A.S., S.S., K.T.B.), University of Pennsylvania, Philadelphia; the Department of Public Health Sciences, University of Virginia, Charlottesville (S.J.R.); the Department of Obstetrics and Gynecology, University of California, Davis, Sacramento (M.D.C.); and the Department of Obstetrics and Gynecology, Montefiore Hospital and Albert Einstein College of Medicine, Bronx, NY (J.A.)
| | - Mitchell D Creinin
- From the Pregnancy Early Access Center (PEACE), Division of Family Planning (C.A.S., S.S.), Department of Obstetrics and Gynecology (C.A.S., S.S., K.T.B.), University of Pennsylvania, Philadelphia; the Department of Public Health Sciences, University of Virginia, Charlottesville (S.J.R.); the Department of Obstetrics and Gynecology, University of California, Davis, Sacramento (M.D.C.); and the Department of Obstetrics and Gynecology, Montefiore Hospital and Albert Einstein College of Medicine, Bronx, NY (J.A.)
| | - Jessica Atrio
- From the Pregnancy Early Access Center (PEACE), Division of Family Planning (C.A.S., S.S.), Department of Obstetrics and Gynecology (C.A.S., S.S., K.T.B.), University of Pennsylvania, Philadelphia; the Department of Public Health Sciences, University of Virginia, Charlottesville (S.J.R.); the Department of Obstetrics and Gynecology, University of California, Davis, Sacramento (M.D.C.); and the Department of Obstetrics and Gynecology, Montefiore Hospital and Albert Einstein College of Medicine, Bronx, NY (J.A.)
| | - Sarita Sonalkar
- From the Pregnancy Early Access Center (PEACE), Division of Family Planning (C.A.S., S.S.), Department of Obstetrics and Gynecology (C.A.S., S.S., K.T.B.), University of Pennsylvania, Philadelphia; the Department of Public Health Sciences, University of Virginia, Charlottesville (S.J.R.); the Department of Obstetrics and Gynecology, University of California, Davis, Sacramento (M.D.C.); and the Department of Obstetrics and Gynecology, Montefiore Hospital and Albert Einstein College of Medicine, Bronx, NY (J.A.)
| | - Sarah J Ratcliffe
- From the Pregnancy Early Access Center (PEACE), Division of Family Planning (C.A.S., S.S.), Department of Obstetrics and Gynecology (C.A.S., S.S., K.T.B.), University of Pennsylvania, Philadelphia; the Department of Public Health Sciences, University of Virginia, Charlottesville (S.J.R.); the Department of Obstetrics and Gynecology, University of California, Davis, Sacramento (M.D.C.); and the Department of Obstetrics and Gynecology, Montefiore Hospital and Albert Einstein College of Medicine, Bronx, NY (J.A.)
| | - Kurt T Barnhart
- From the Pregnancy Early Access Center (PEACE), Division of Family Planning (C.A.S., S.S.), Department of Obstetrics and Gynecology (C.A.S., S.S., K.T.B.), University of Pennsylvania, Philadelphia; the Department of Public Health Sciences, University of Virginia, Charlottesville (S.J.R.); the Department of Obstetrics and Gynecology, University of California, Davis, Sacramento (M.D.C.); and the Department of Obstetrics and Gynecology, Montefiore Hospital and Albert Einstein College of Medicine, Bronx, NY (J.A.)
| |
Collapse
|
47
|
Sonalkar S, McClusky J, Vanjani R, Vragovic O, Sammel M, Borgatta L. Postabortion long-acting reversible contraception desire in women counselled using Bedsider.org versus standard counselling: a randomised trial. BMJ Sex Reprod Health 2018; 44:bmjsrh-2017-200047. [PMID: 29972363 PMCID: PMC6269223 DOI: 10.1136/bmjsrh-2017-200047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Affiliation(s)
- Sarita Sonalkar
- 85 E. Concord St, 6 Floor, Boston University School of Medicine, Boston, MA 02118
| | - Jessica McClusky
- 85 E. Concord St, 6 Floor, Boston University School of Medicine, Boston, MA 02118
| | - Rachna Vanjani
- 85 E. Concord St, 6 Floor, Boston University School of Medicine, Boston, MA 02118
| | - Olivera Vragovic
- 85 E. Concord St, 6 Floor, Boston University School of Medicine, Boston, MA 02118
| | - Mary Sammel
- Department of Biostatics and Epidemiology, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Blockley Hall, 423 Guardian Drive, Philadelphia, PA, 19104
| | - Lynn Borgatta
- 85 E. Concord St, 6 Floor, Boston University School of Medicine, Boston, MA 02118
| |
Collapse
|
48
|
Hunter T, Gurney EP, Schreiber C, McAllister A, Sonalkar S. Probability of Pregnancy after Intended Postplacental versus Interval Intrauterine Device Placement [3F]. Obstet Gynecol 2018. [DOI: 10.1097/01.aog.0000533314.17303.ab] [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: 11/25/2022]
|
49
|
Sonalkar S, Ogden SN, Tran LK, Chen AY. Comparison of complications associated with induction by misoprostol versus dilation and evacuation for second-trimester abortion. Int J Gynaecol Obstet 2017; 138:272-275. [DOI: 10.1002/ijgo.12229] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 04/16/2017] [Accepted: 06/02/2017] [Indexed: 11/12/2022]
Affiliation(s)
- Sarita Sonalkar
- Perelman School of Medicine at the University of Pennsylvania; Philadelphia PA USA
| | - Shannon N. Ogden
- Perelman School of Medicine at the University of Pennsylvania; Philadelphia PA USA
| | | | - Angela Y. Chen
- University of California - Los Angeles; Los Angeles CA USA
| |
Collapse
|
50
|
Sonalkar S, Gaffield ME. Introducing the World Health Organization Postpartum Family Planning Compendium. Int J Gynaecol Obstet 2016; 136:2-5. [PMID: 28099711 PMCID: PMC5310387 DOI: 10.1002/ijgo.12003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Revised: 07/07/2016] [Accepted: 09/30/2016] [Indexed: 11/12/2022]
Abstract
The postpartum period offers multiple opportunities for healthcare providers to assist with family planning decision making. However, there are also many changing factors during the first year after delivery that can affect family planning choices. Given that several different documents have addressed WHO guidance on postpartum family planning, the electronic WHO Postpartum Family Planning Compendium (http://srhr.org/postpartumfp) has been introduced. This resource integrates essential guidance on postpartum family planning for clinicians, program managers, and policy makers. The development of the Compendium included consultations with family planning experts, key international stakeholders, and web developers. Once the website had been created, user testing by family planning experts allowed for improvements to be made before the official launch. Future directions are adaptation of the website into a mobile application that can be more easily integrated to low‐resource settings, and translation of the content into French and Spanish. The WHO Postpartum Family Planning Compendium is an electronic tool that integrates WHO guidance on postpartum family planning.
Collapse
Affiliation(s)
- Sarita Sonalkar
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | |
Collapse
|