Intrauterine Device Placement Success for Adolescents and Young Adults at Community-Based Reproductive Health Clinics

BACKGROUND

Despite the endorsement of intrauterine device (IUD) use in adolescents and young adults (AYAs) by leading professional organizations and demonstrated acceptance and desirability by AYAs, clinicians may worry about the procedural difficulty of IUD device placement in younger patients.

OBJECTIVE

The aim of this study was to evaluate the clinical outcomes of first-attempt IUD placement in an AYA population by vaginal delivery (VD) history.

STUDY DESIGN

We performed a retrospective cohort study of patients under 25 years old at reproductive health clinics with an IUD placement attempt between January 1 and August 31, 2017. We abstracted sociodemographic characteristics, pregnancy history, and procedural characteristics including complications. Bivariate analyses compared successful first-attempt IUD placement by VD history. We also assessed the frequency of secondary clinical outcomes including ancillary measures used, provider type, symptoms reported during the procedure, and complications.

RESULTS

We included 1325 participants (median age = 21.3 years), including 42 (3.2%) with a previous VD. Nearly all IUD placements were successful on the first attempt (n = 1301, 98.2%) and performed by advanced practice clinicians (n = 1314, 99.2%). First-attempt IUD placement success was similar in those participants with and without VD (P > .999). Ancillary measures other than nonsteroidal anti-inflammatory drugs were used infrequently (n = 16, 3.6%). Among participants with an unsuccessful placement, 66.7% returned, and all had a successful IUD placement on the second attempt. Documented complications within 6 months of placement were rare (n = 29) and mostly comprised expulsions (n = 27, 93.1%).

CONCLUSION

IUD placement success among AYAs at community-based reproductive health clinics is high and is not associated with a history of VD.

More than tears: associations between exposure to chemical agents used by law enforcement and adverse reproductive health outcomes

Despite routine law enforcement use of chemical agents for crowd control, the reproductive health safety profiles of these products are unknown. Moreover, limited evidence has documented a link between such exposures and adverse reproductive health outcomes including abnormal uterine bleeding and potential pregnancy disruption. This cross-sectional study examined reproductive outcomes in adults with uteri exposed to chemical agents used by law enforcement, more commonly known as "tear gas". Participants were recruited through social media in the wake of police violence protests. Of the 1,276 participants included in analysis, 83% reported experiencing at least one of the outcomes of interest, included uterine cramping (69%), early menstrual bleeding (55%), breast tenderness (30%), and delayed menstrual bleeding (19%). Chemical agent exposure was significantly associated with higher odds of an adverse reproductive health outcome, those with 5 days or more of exposure have 2.6 times the odds (CI: 1.61, 4.22) of adverse outcomes and having a perception that one's menstruation may fluctuate according to psychosocial stressors was associated (OR = 1.94, CI: 1.36, 2.79) with a higher odds of an adverse reproductive health experience. These findings suggest a potential relationship between exposure to chemical agents and adverse reproductive health outcomes. Given the pervasive use of these chemical agents and their potential for reproductive health harm, further investigation into the safety of these products and their impacts on individual and community health is warranted urgently.

Willingness to use novel reversible methods of male birth control: a community-based survey of cisgender men in the United States

BACKGROUND

There is high global demand for new methods of male birth control (MBC). However, contemporary evidence regarding men's method-specific attitudes and their determinants is sparse.

METHODS

Non-sterilized cisgender men ages 18-45 with recent history of female sex partners were surveyed at a large community event in the Midwestern US. We examined variation in participants' willingness to use MBC by method (gel, pill, injection, implant, and vas occlusion), potential side effects, and potential barriers. We estimated crude and adjusted prevalence ratios (aPRs) for associations between participant characteristics and willingness to use ≥ 1 MBC method.

RESULTS

Overall, 72% of participants (n = 187; mean age, 29) were very willing to use ≥ 1 MBC method although support for individual methods ranged widely from 62% (pill) to 24% (vas occlusion). In bivariate analysis of sociodemographic and health characteristics, few demonstrated associations with MBC willingness. In a multivariable model, willingness was independently related to age (30-39 vs. 18-29 years old, aPR = 1.24, 95% CI 1.04-1.48) and having ever been tested for HIV (aPR = 1.27, 95% CI 1.07-1.51). Willingness to tolerate side effects was < 10% for most items. The most commonly endorsed barriers to MBC use were high cost (77%) and side effects (66%).

CONCLUSIONS

Enthusiasm for MBC was high but waned in the context of potential side effects and barriers. Additional research on MBC attitudes in socioeconomically and culturally diverse populations worldwide is sorely needed.

Mailing abortion pills does not delay care: A cohort study comparing mailed to in-person dispensing of abortion medications in the United States

OBJECTIVE

Given the substantial barriers to abortion access in the United States, many clinics now mail patients abortion medications. We examined whether dispensing the medications by mail prolonged time to medication use.

STUDY DESIGN

We analyzed data from no-test medication abortions with medication provided either by mail or in a clinic from 11 United States clinics from February 2020 to January 2021. We examined mean number of days from patients' first contact with the clinic to mifepristone ingestion, its two-component intervals (first contact to medication dispensing and dispensing to mifepristone ingestion), and pregnancy duration at mifepristone ingestion. We used Poisson regression to compare mean outcomes across three dispensing methods: in-person, mailed from the clinic, and mailed from a mail-order pharmacy.

RESULTS

Among the 2600 records, patients took mifepristone on average at 49 days of gestation (95% CI, 47-51) and 7 days (95% CI, 4-10) after first contact. Mean time from first contact to mifepristone ingestion was 6 days when medications were dispensed in-person and 9 days when mailed (p = 0.38). While time from first contact to dispensing was similar across methods (6 days in-person, 5 days mailed, p = 0.77), more time elapsed from dispensing to mifepristone ingestion when medications were mailed (4 days from clinic, 5 days from mail-order pharmacy) versus dispensed in-person (0.3 days, p < 0.001). Time to mifepristone ingestion was shorter with higher pregnancy duration. Pregnancy duration at ingestion was similar across methods (48 days in-person, 50 days mailed).

CONCLUSIONS

Mailing medications did not significantly prolong time from patients' first contact with the clinic to mifepristone ingestion or increase pregnancy duration at mifepristone ingestion.

IMPLICATIONS

Abortion providers should offer a range of medication abortion dispensing options, prioritizing patient preference.

Evaluation of Strategies to Improve Uptake of Expedited Partner Therapy for Chlamydia trachomatis Treatment in Minnesota: A Decision Analytic Model

Background. Despite the established effectiveness of expedited partner therapy (EPT) in partner treatment of bacterial sexually transmitted infections (STI), the practice is underutilized. Objective. To estimate the relative effectiveness of strategies to increase EPT uptake (numbers of partners treated for chlamydia). Methods. We developed a care cascade model of cumulative probabilities to estimate the number of partners treated under strategies to increase EPT uptake in Minnesota. The care cascade model used data from clinical trials, population-based studies, and Minnesota chlamydia surveillance as well as in-depth interviews of health providers who regularly treat STI patients and a statewide survey of health providers across Minnesota. Results. Several strategies could improve EPT uptake among providers, including facilitating treatment payment (additional 1,932 partners treated) and implementing electronic health record reminders (additional 1,755 partners treated). Addressing concerns about liability would have the greatest effect, resulting in 2,187 additional partners treated. Conclusions. Providers expressed openness to offering EPT under several scenarios, which reflect differences in knowledge about EPT, its legality, and potential risks to patients. While addressing concerns about provider liability would have the greatest effect on number of partners treated, provider education and procedural changes could make a substantial impact.

Highlights

Addressing provider concerns about expedited partner therapy (EPT) legality and its potential risks would result in the most partners treated for chlamydia.EPT alerts and electronic EPT prescriptions may also streamline partner treatment.Provider education about the legality of EPT and its potential risks and training in counseling patients on EPT could also increase uptake.

A Statewide Mixed-Methods Study of Provider Knowledge and Behavior Administering Expedited Partner Therapy for Chlamydia and Gonorrhea

BACKGROUND

Expedited partner therapy (EPT) refers to the practice of having patients diagnosed with chlamydia or gonorrhea deliver medication directly to their partner(s) to treat them presumptively for infection. Although EPT facilitates timely treatment and prevents reinfection, it remains underused. We used findings from key informant interviews to design and implement a statewide survey to estimate knowledge and utilization of EPT and to identify barriers and facilitators to EPT among Minnesota providers.

METHODS

From November to December 2020, we carried out 15 interviews with health providers who currently provide EPT and coded interviews by recurring themes. We then conducted a statewide online survey on sexually transmitted infection treatment and barriers to EPT, from December 2020 to March 2021. We disseminated the survey to all licensed Minnesota health providers, and those who reported treating bacterial sexually transmitted infections in the past year were included in the study.

RESULTS

Interview themes included the importance of direct provision of partner medication, administrative/pharmacy barriers to treatment, inclusive EPT eligibility, and patient counseling. Of the 623 health providers who completed the online survey, only 70% thought EPT was legal and only 37% currently offer EPT. Of those who did not provide EPT, 78% said they would under certain circumstances. Barriers included concerns about safety/liability of prescribing without a medical examination, administrative concerns about prescriptions, and patient acceptance.

CONCLUSIONS

Given that over a quarter of respondents did not know expedited partner therapy (EPT)'s legal status, improving provider education may increase EPT provision. More research is needed on system-level barriers and patient acceptance of solutions identified in this study.

Outcomes and Safety of History-Based Screening for Medication Abortion: A Retrospective Multicenter Cohort Study

IMPORTANCE

Screening for medication abortion eligibility typically includes ultrasonography or pelvic examination. To reduce physical contact during the COVID-19 pandemic, many clinicians stopped requiring tests before medication abortion and instead screened patients for pregnancy duration and ectopic pregnancy risk by history alone. However, few US-based studies have been conducted on the outcomes and safety of this novel model of care.

OBJECTIVE

To evaluate the outcomes and safety of a history-based screening, no-test approach to medication abortion care.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study included patients obtaining a medication abortion without preabortion ultrasonography or pelvic examination between February 1, 2020, and January 31, 2021, at 14 independent, Planned Parenthood, academic-affiliated, and online-only clinics throughout the US.

EXPOSURES

Medications for abortion provided without preabortion ultrasonography or pelvic examination and dispensed to patients in person or by mail.

MAIN OUTCOMES AND MEASURES

Effectiveness, defined as complete abortion after 200 μg of mifepristone and up to 1600 μg of misoprostol without additional intervention, and major abortion-related adverse events, defined as hospital admission, major surgery, or blood transfusion.

RESULTS

The study included data on 3779 patients with eligible abortions. The study participants were racially and ethnically diverse and included 870 (23.0%) Black patients, 533 (14.1%) Latinx/Hispanic patients, 1623 (42.9%) White patients, and 327 (8.7%) who identified as multiracial or with other racial or ethnic groups. For most (2626 [69.5%]), it was their first medication abortion. Patients lived in 34 states, and 2785 (73.7%) lived in urban areas. In 2511 (66.4%) abortions, the medications were dispensed in person; in the other 1268 (33.6%), they were mailed to the patient. Follow-up data were obtained for 2825 abortions (74.8%), and multiple imputation was used to account for missing data. Across the sample, 12 abortions (0.54%; 95% CI, 0.18%-0.90%) were followed by major abortion-related adverse events, and 4 patients (0.22%; 95% CI, 0.00%-0.45%) were treated for ectopic pregnancies. Follow-up identified 9 (0.40%; 95% CI, 0.00%-0.84%) patients who had pregnancy durations of greater than 70 days on the date the mifepristone was dispensed that were not identified at screening. The adjusted effectiveness rate was 94.8% (95% CI, 93.6%-95.9%). Effectiveness was similar when medications were dispensed in person (95.4%; 95% CI, 94.1%-96.7%) or mailed (93.3%; 95% CI, 90.7%-95.9%).

CONCLUSIONS AND RELEVANCE

In this cohort study, screening for medication abortion eligibility by history alone was effective and safe with either in-person dispensing or mailing of medications, resulting in outcomes similar to published rates of models involving ultrasonography or pelvic examination. This approach may facilitate more equitable access to this essential service by increasing the types of clinicians and locations offering abortion care.

Expansion of a direct-to-patient telemedicine abortion service in the United States and experience during the COVID-19 pandemic

OBJECTIVE

To present updated evidence on the safety, efficacy and acceptability of a direct-to-patient telemedicine abortion service and describe how the service functioned during the COVID-19 pandemic.

STUDY DESIGN

We offered the study at 10 sites that provided the service in 13 states and Washington DC. Interested individuals obtained any needed preabortion tests locally and had a videoconference with a study clinician. Sites sent study packages containing mifepristone and misoprostol by mail and had remote follow-up consultations within one month by telephone (or by online survey, if the participant could not be reached) to evaluate abortion completeness. The analysis was descriptive.

RESULTS

We mailed 1390 packages between May 2016 and September 2020. Of the 83% (1157/1390) of abortions for which we obtained outcome information, 95% (1103/1157) were completed without a procedure. Participants made 70 unplanned visits to emergency rooms or urgent care centers for reasons related to the abortion (6%), and 10 serious adverse events occurred, including 5 transfusions (0.4%). Enrollment increased substantially with the onset of COVID-19. Although a screening ultrasound was required, sites determined in 52% (346/669) of abortions that occurred during COVID that those participants should not get the test to protect their health. Use of urine pregnancy test to confirm abortion completion increased from 67% (144/214) in the 6 months prior to COVID to 90% (602/669) in the 6 months during COVID. Nearly all satisfaction questionnaires (99%, 1013/1022) recorded that participants were satisfied with the service.

CONCLUSIONS

This direct-to-patient telemedicine service was safe, effective, and acceptable, and supports the claim that there is no medical reason for mifepristone to be dispensed in clinics as required by the Food and Drug Administration. In some cases, participants did not need to visit any facilities to obtain the service, which was critical to protecting patient safety during the COVID-19 pandemic.

IMPLICATIONS

Medical abortion using telemedicine and mail is effective and can be safely provided without a pretreatment ultrasound. This method of service delivery has the potential to greatly improve access to abortion care in the United States.

Risk of Pregnancy With Levonorgestrel-Releasing Intrauterine System Placement 6-14 Days After Unprotected Sexual Intercourse

Pregnancy is unlikely when a levonorgestrel-releasing intrauterine system (52 mg) is placed 6–14 days after unprotected intercourse.

Maternal and neonatal outcomes among incarcerated women who gave birth in custody

BACKGROUND

In the United States, the population of incarcerated women has increased by more than 600% since the 1980s. With this rise, correctional facilities have faced new challenges meeting the health care needs of women, especially those who are pregnant. This retrospective cohort study sought to describe five indicators of maternal and neonatal health among women who gave birth in custody, and to compare outcomes among incarcerated women who did and did not receive enhanced pregnancy support.

METHODS

We used deidentified electronic health records (EHRs) to examine maternal and neonatal birth outcomes (ie, mode of birth, low birthweight, preterm birth, APGAR score, NICU admission) among women who gave birth in custody. Regression models examined differences in outcomes between women who received enhanced pregnancy support-group prenatal education and one-on-one doula visits-and a historical control group of women who received standard prenatal care.

RESULTS

Adverse maternal and neonatal birth outcomes in this sample were rare. No differences in outcomes were found between incarcerated women who received enhanced pregnancy support and the historical control group.

CONCLUSIONS

Despite evidence for the benefits of enhanced pregnancy support in the general population, this study did not find differences in outcomes between incarcerated women who did and did not receive support. Integrated data from prison and hospital records are innovative, but effect measurement is limited by sample size. Future research should include primary data collection on maternal, neonatal, and dyadic outcomes longitudinally and across prisons.

Contraceptive counselling: an essential travel medicine service

Non-physician healthcare practitioners are increasingly providing pre-travel care, including completing risk assessments and prescribing medications and vaccines. While this increases pre-travel care access, the quality of this care must be ensured. Doing so requires translation of existing prescribing competencies and best practices in competence development into policies regulating pre-travel care.

Use of an endotracheal tube for surgical abortion complicated by a leiomyomatous uterus: a case report

Background

Abnormal uterine anatomy, especially leiomyomas, can significantly impact the difficulty and potential morbidity of surgical uterine evacuation. To avoid hysterotomy and/or hysterectomy, limited evidence exists to guide surgical uterine evacuation when pregnancy tissue is inaccessible with routine instruments.

Case presentation

A 41-year-old G4P1021 African American woman at 14 4/7 weeks’ gestation was referred for surgical-induced abortion in the setting of an enlarged leiomyomatous uterus. Two large opposing leiomyomas at the internal cervical os rendered pregnancy tissue inaccessible with routine gynecologic surgical instruments. With ultrasound guidance, an endotracheal tube was connected to routine electric suction and utilized to complete uterine evacuation.

Conclusions

With distorted or markedly enlarged uterine anatomy rendering pregnancy tissue inaccessible with routine surgical instruments, the minimally invasive use of an endotracheal tube may aid completion of uterine evacuation for surgical uterine evacuation.

YouTube and the single-rod contraceptive implant: a content analysis

BACKGROUND

Since the internet has become an important source of contraceptive information with YouTube.com as the second most visited site, we analysed contraceptive implant YouTube videos for content and clinical accuracy.

METHODS

Using the terms 'contraceptive implant', 'Nexplanon' and 'Implanon', the top 20 results on YouTube by relevance and view count were identified. After excluding duplicates, single-rod implant videos in English were included. Videos were classified as providing a professional or patient perspective. Views, duration and comments were noted. Videos were rated for reliability, global quality scale and whether they were positive or negative about the implant. Inter-rater agreement was measured.

RESULTS

A total of 120 videos were retrieved; 52 were eligible for review. Less than 23% were professional videos; the majority reported patient experience (46% testimonials, 27% real-time procedure videos, 4% other). Patient videos had been posted a significantly longer duration of time than professional videos (364 vs 188 days, p=0.02), were less reliable (p≤0.0001) and were of lower global quality (p<0.0001). Some 61% of implant testimonial videos were rated as 'positive experiences' and inter-rater agreement was very good (κ=0.81). All testimonials mentioned side effects, commonly irregular bleeding and discomfort with insertion. A minority (26%) reported misinformation.

CONCLUSIONS

This study found that most of the information on YouTube pertaining to contraceptive implants is accurate, is presented from the patient's perspective, and promotes the method's use.