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Rocca CH, Muñoz I, Rao L, Levin S, Tzvieli O, Harper CC. Measuring a Critical Component of Contraceptive Decision Making: The Contraceptive Concerns and Beliefs Scale. Matern Child Health J 2024; 28:847-857. [PMID: 38194129 PMCID: PMC11001673 DOI: 10.1007/s10995-023-03856-5] [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] [Accepted: 12/10/2023] [Indexed: 01/10/2024]
Abstract
INTRODUCTION Concerns about safety and side effects from contraceptives are widespread and related to reluctance to use them. Measuring these concerns is an essential component of understanding contraceptive decision-making and guiding contraceptive and interpregnancy clinical care. METHODS We used qualitative research and item response theory to develop and test a psychometric instrument to measure contraceptive concerns and beliefs. We developed 55 candidate scale items and tested them among 572 adolescents and adults across nine California healthcare facilities in 2019-2020. We derived a 6-item scale and assessed differences by age and social determinants of health with multivariable regression. RESULTS In qualitative data, participants voiced both concerns and positive beliefs about contraception. Quantitative survey respondents were aged 21 years on average, and 24% were parous. Over half (54%) worried contraception has dangerous side effects, and 39% worried it is unnatural. The mean Contraceptive Concerns score, increasing with higher concerns, was 1.85 (SD: 1.00, range 0-4, α = 0.81). Items fit a partial credit item response model and met prespecified criteria for internal structure validity. Contraceptive use declined with increasing Concerns score (adjusted prevalence ratio [aPR] = 0.81 [0.72-0.92]). Scores were elevated among Black (mean: 2.06; aβ = 0.34 [0.09, 0.59]) and Multiracial or other race (2.11; aβ = 0.34 [0.02, 0.66]) respondents vs. White (1.66), but not Latinx respondents (1.81; aβ = 0.11 [- 0.11, 0.33]). Scores were also elevated among participants with lower maternal education (high school/Associate's 1.89 versus college 1.60; aβ = 0.28 [0.04, 0.53]). DISCUSSION The psychometrically robust Concerns instrument can be used in research to measure autonomous contraceptive decision-making and to design person-centered care.
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Affiliation(s)
- Corinne H Rocca
- Advancing Standards in Reproductive Health (ANSIRH), Department of Obstetrics, Gynecology and Reproductive Sciences, School of Medicine, University of California, San Francisco, Oakland, CA, USA.
| | - Isabel Muñoz
- Advancing Standards in Reproductive Health (ANSIRH), Department of Obstetrics, Gynecology and Reproductive Sciences, School of Medicine, University of California, San Francisco, Oakland, CA, USA
- Department of Epidemiology and Biostatistics, School of Public Health, University of California, Berkeley, Berkeley, CA, USA
| | - Lavanya Rao
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, School of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Sara Levin
- Division of Public Health, Contra Costa Health, Martinez, CA, USA
| | - Ori Tzvieli
- Division of Public Health, Contra Costa Health, Martinez, CA, USA
| | - Cynthia C Harper
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, School of Medicine, University of California, San Francisco, San Francisco, CA, USA
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Harper CC, Yarger J, Mangurian C, Hopkins K, Rossetto I, Elmes S, Hecht HK, Sanchez A, Hernandez R, Shokat M, Steinberg JR. Mental Health Distress and Delayed Contraception Among Older Adolescents and Young Adults. J Womens Health (Larchmt) 2024. [PMID: 38465503 DOI: 10.1089/jwh.2023.0549] [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] [Indexed: 03/12/2024] Open
Abstract
Background: Symptoms of mental distress increased sharply during the COVID-19 pandemic, especially among older adolescents and young adults. Mental health distress may make it more challenging for young people to seek other needed health care, including contraception. This study explored the association of symptoms of depression, anxiety, and stress with delays in getting a contraceptive method or prescription. Materials and Methods: Data from a supplementary study (May 15, 2020-March 20, 2023) to a cluster randomized trial in 29 sites in Texas and California were used. The diverse study sample included community college students assigned female at birth of ages 18-29 years (n = 1,665 with 7,023 observations over time). We measured the association of depression (CES-D [Center for Epidemiologic Studies Depression Scale]) or anxiety and stress (DASS-21 [Depression Anxiety Stress Scales]) symptoms with delayed contraceptive care-seeking with mixed-effects multivariable regression with random effects for individual and site. We controlled for age and sociodemographic factors important for access to care. Results: Over one-third of participants (35%) reported they delayed getting the contraceptive method they needed. Multivariable regression results showed increased odds of delayed contraceptive care among participants with symptoms of depression (adjusted odds ratio [aOR] 1.58, 95% confidence interval [CI] 1.27-1.96). Likewise, delays were associated with anxiety and stress symptoms (aOR 1.46, 95% CI 1.17-1.82). Adolescents were more likely to delay seeking contraception than young adults (aOR 1.32, 95% CI 1.07-1.63). Conclusions: Results showed a strong association between mental distress and delayed contraception. Interventions are needed to increase contraceptive access for young people delaying care, along with supportive mental health care services, including for adolescents who face elevated odds of delay. ClinicalTrials.gov Identifier: NCT03519685.
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Affiliation(s)
- Cynthia C Harper
- Department of Obstetrics, Gynecology & Reproductive Sciences, Bixby Center for Global Reproductive Health, School of Medicine, University of California, San Francisco, California, USA
| | - Jennifer Yarger
- Department of Obstetrics, Gynecology & Reproductive Sciences, Bixby Center for Global Reproductive Health, School of Medicine, University of California, San Francisco, California, USA
| | - Christina Mangurian
- Department of Psychiatry & Behavioral Sciences, Weill Institute for Neurosciences, School of Medicine, University of California, San Francisco, California, USA
| | - Kristine Hopkins
- Population Research Center, University of Texas at Austin, Austin, Texas, USA
| | - Irene Rossetto
- Population Research Center, University of Texas at Austin, Austin, Texas, USA
| | - Sarah Elmes
- Department of Obstetrics, Gynecology & Reproductive Sciences, Bixby Center for Global Reproductive Health, School of Medicine, University of California, San Francisco, California, USA
| | - Hannah K Hecht
- Department of Obstetrics, Gynecology & Reproductive Sciences, Bixby Center for Global Reproductive Health, School of Medicine, University of California, San Francisco, California, USA
| | - Audrey Sanchez
- Population Research Center, University of Texas at Austin, Austin, Texas, USA
| | | | - Mitra Shokat
- School of Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Julia R Steinberg
- Department of Family Science, School of Public Health, University of Maryland, College Park, Maryland, USA
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Yarger J, Hopkins K, Elmes S, Rossetto I, Van Liefde D, De La Melena S, Harper CC. Use of telemedicine to obtain contraception among young adults: Inequities by health insurance. Contraception 2024:110419. [PMID: 38467325 DOI: 10.1016/j.contraception.2024.110419] [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: 09/12/2023] [Revised: 12/19/2023] [Accepted: 03/06/2024] [Indexed: 03/13/2024]
Abstract
OBJECTIVE The objective of this study was to describe use of telemedicine for contraception in a sample of young adults and examine differences by health insurance coverage. STUDY DESIGN We analyzed survey data collected May 2020-July 2022 from individuals at risk of pregnancy aged 18-29 recruited at 29 community colleges in California and Texas. We used multivariable mixed-effects logistic regression models with random effects for site and individual to compare use of telemedicine to obtain contraception by insurance status, sociodemographic characteristics, and state. RESULTS Our analytic sample included 6,465 observations from 1,630 individuals. Participants reported using a contraceptive method obtained through telemedicine in just 6% of observations. Uninsured participants were significantly less likely than those privately insured to use contraception obtained through telemedicine (adjusted odds ratio [aOR], 0.54; 95% confidence interval [CI], 0.31-0.97), as were participants who did not know their insurance status (aOR, 0.54; 95% CI, 0.29-0.99). Texas participants were less likely to use contraception obtained via telemedicine than those in California (aOR, 0.42; CI: 0.25-0.69). CONCLUSIONS Few young people in this study obtained contraception through telemedicine, and insurance was crucial for access in both states. IMPLICATIONS Although telemedicine holds promise for increasing contraceptive access, we found that few young adults were using it, particularly among the uninsured. Efforts are needed to improve young adults' access to telemedicine for contraception and address insurance disparities.
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Affiliation(s)
- Jennifer Yarger
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco; Department of Epidemiology and Biostatistics, University of California, San Francisco; Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco.
| | | | - Sarah Elmes
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco
| | - Irene Rossetto
- Population Research Center, University of Texas at Austin
| | - Danielle Van Liefde
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco
| | - Stephanie De La Melena
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco
| | - Cynthia C Harper
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco; Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco
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Comfort AB, Alvarez A, Goodman S, Upadhyay U, Mengesha B, Karlin J, Shokat M, Blum M, Harper CC. Provision of DMPA-SC for self-administration in different practice settings during the COVID-19 pandemic: Data from providers across the United States. Contraception 2024; 131:110360. [PMID: 38158075 PMCID: PMC11024673 DOI: 10.1016/j.contraception.2023.110360] [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: 06/21/2023] [Revised: 12/20/2023] [Accepted: 12/22/2023] [Indexed: 01/03/2024]
Abstract
OBJECTIVES Depot medroxyprogesterone acetate-subcutaneous (DMPA-SC) can be prescribed through telemedicine and self-administered, but data about availability, particularly during the COVID-19 pandemic, are limited. This study assessed changes in the availability of DMPA-SC for self-administration during the pandemic. STUDY DESIGN This study used survey data from a convenience sample of US providers engaged in contraceptive care and participating in a Continuing Medical Education-accredited contraceptive training (April 2020-April 2022; n = 849). Providers were recruited from across 503 clinics, including primary care and family planning clinics, public health departments, college and school-based health centers, independent abortion care clinics, and outpatient clinics in hospital settings. Measures included the availability of DMPA-SC for self-administration before and during the pandemic and the use of telemedicine. We used Poisson regression models and cluster-robust errors by clinic, adjusting for region, time of survey, and clinic size, to assess clinic availability of DMPA-SC for self-administration by practice setting. RESULTS Compared to the prepandemic period (4%), the availability of DMPA-SC for self-administration increased significantly during the pandemic (14%) (adjusted prevalence ratios [aPR] 3.43, 95% CI [2.43-4.85]). During the pandemic, independent abortion clinics were more likely to offer DMPA-SC for self-administration compared to primary care clinics (aPR 2.44, 95% CI [1.10-5.41]). Clinics receiving Title X funds were also more likely to provide DMPA-SC for self-administration during the pandemic compared to other clinics (aPR 2.32, 95% CI [1.57-3.43]), and more likely to offer DMPA-SC for self-administration through telemedicine (aPR 2.35, 95% CI [1.52-3.63]). Compared to the early pandemic period (April-September 2022), telemedicine access to DMPA-SC for self-administration was highest during the later pandemic time period (October 2021-April 2022) (aPR 2.10, 95% CI [1.06-4.17]). CONCLUSIONS The availability of DMPA-SC for self-administration significantly increased during the pandemic with differences by practice setting and Title X funding. However, overall method availability remains persistently low. IMPLICATIONS Despite increased availability of DMPA-SC for self-administration among US contraceptive providers during the COVID-19 pandemic, there remains a need to train providers, educate patients, and remove barriers to ensure broader availability of this method across different practice settings.
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Affiliation(s)
- Alison B Comfort
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Bixby Center for Global Reproductive Health, University of California San Francisco, San Francisco, CA, United States.
| | - Alejandra Alvarez
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Bixby Center for Global Reproductive Health, University of California San Francisco, San Francisco, CA, United States
| | - Suzan Goodman
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Bixby Center for Global Reproductive Health, University of California San Francisco, San Francisco, CA, United States
| | - Ushma Upadhyay
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Bixby Center for Global Reproductive Health, University of California San Francisco, San Francisco, CA, United States
| | - Biftu Mengesha
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Bixby Center for Global Reproductive Health, University of California San Francisco, San Francisco, CA, United States
| | - Jennifer Karlin
- Department of Family and Community Medicine, University of California Davis, Sacramento, CA, United States
| | - Mitra Shokat
- OHSU-PSU School of Public Health, Portland, OR, United States
| | - Maya Blum
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Bixby Center for Global Reproductive Health, University of California San Francisco, San Francisco, CA, United States
| | - Cynthia C Harper
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Bixby Center for Global Reproductive Health, University of California San Francisco, San Francisco, CA, United States
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Watson A, Yarger J, Sedlander E, Urbina J, Hopkins K, Rodriguez MI, Fuentes L, Harper CC. Concern that contraception affects future fertility: How common is this concern among young people and does it stop them from using contraception? Contracept X 2023; 5:100103. [PMID: 38162189 PMCID: PMC10755709 DOI: 10.1016/j.conx.2023.100103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 11/16/2023] [Accepted: 11/26/2023] [Indexed: 01/03/2024] Open
Abstract
Objectives This study examines the concern that contraception affects future fertility among community college students and its association with contraceptive use. Study design We used baseline data from a randomized controlled trial with 2060 community college students assigned female at birth. We used mixed-effects multivariate logistic regression adjusted for clustered data to assess sociodemographic factors associated with concerns about contraception affecting future fertility and to test the association between this concern and contraceptive use. Results Most participants (69%) worried about contraception affecting their future fertility. Multivariable results indicated that first-generation college students (adjusted odds ratio [aOR], 1.24; 95% confidence interval [CI], 1.01-1.55) and non-English speakers at home (aOR, 1.30; 95% CI, 1.04-1.64) were more concerned. Racial and ethnic differences were significant, with Black non-Hispanic (aOR, 2.83; 95% CI, 1.70-4.70), Asian/Pacific Islander non-Hispanic (aOR, 2.12; 95% CI, 1.43-3.14), and Hispanic (aOR, 1.54; 95% CI, 1.17-2.02) participants more likely to be concerned than White non-Hispanic counterparts. Participants who received contraceptive services in the past year had lower odds of this concern (aOR, 0.72; 95% CI 0.59-0.88). Furthermore, participants with this concern had lower odds of using contraception (aOR, 0.67; 95% CI, 0.49-0.91), especially hormonal contraception (aOR, 0.77; 95% CI, 0.61-0.97). Conclusions Most students feared contraception's impact on fertility, and this fear was associated with not using contraception. Disparities in this concern may be tied to discrimination, reproductive coercion, and limited reproductive health care access. Addressing concerns about contraception affecting future fertility is crucial to person-centered contraceptive counseling. Implications This study examines the concern that contraception affects future fertility among sexually active female community college students and its impact on contraceptive use. Most participants expressed concerns about contraception affecting future fertility. Addressing future fertility concerns in patient-centered contraceptive counseling is crucial for reaching young people.
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Affiliation(s)
- Annalisa Watson
- School of Public Health, University of California, Berkeley, CA, United States
- Department of Obstetrics, Gynecology and Reproductive Sciences, Bixby Center for Global Reproductive Health, University of California, San Francisco, CA, United States
| | - Jennifer Yarger
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, CA, United States
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, United States
| | - Erica Sedlander
- Department of Social and Behavioral Sciences, Institute for Health and Aging, University of California, San Francisco, CA, United States
| | - Josephine Urbina
- Department of Obstetrics, Gynecology and Reproductive Sciences, Bixby Center for Global Reproductive Health, University of California, San Francisco, CA, United States
| | - Kristine Hopkins
- Population Research Center, University of Texas at Austin, Austin, TX, United States
| | - Maria I. Rodriguez
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, OR, United States
| | - Liza Fuentes
- Boston Medical Center, Boston, MA, United States
| | - Cynthia C. Harper
- Department of Obstetrics, Gynecology and Reproductive Sciences, Bixby Center for Global Reproductive Health, University of California, San Francisco, CA, United States
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, CA, United States
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Hopkins K, Yarger J, Rossetto I, Sanchez A, Brown E, Elmes S, Mantaro T, White K, Harper CC. Use of preferred contraceptive method among young adults in Texas and California: A comparison by state and insurance coverage. PLoS One 2023; 18:e0290726. [PMID: 37651402 PMCID: PMC10470945 DOI: 10.1371/journal.pone.0290726] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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] [Received: 01/17/2023] [Accepted: 08/15/2023] [Indexed: 09/02/2023] Open
Abstract
BACKGROUND Young people's ability to use their preferred contraceptive method is an indicator of reproductive autonomy and healthcare access. State policies can hinder or facilitate access to a preferred contraceptive method. OBJECTIVE This study compared use of preferred contraceptive method in Texas and California, states with contrasting health policy contexts that impact health insurance coverage and access to subsidized family planning services. METHODS We used baseline survey data from an ongoing cluster randomized controlled trial of sexually active students, assigned female at birth, ages 18-25, at 29 community colleges in Texas and California (N = 1,974). We described contraceptive preferences and use, as well as reasons for nonuse of a preferred method. We conducted multivariable-adjusted mixed-effects logistic regression analyses for clustered data, and then calculated the predicted probability of using a preferred contraceptive method in Texas and California by insurance status. RESULTS More Texas participants were uninsured than Californians (30% vs. 8%, p<0.001). Thirty-six percent of Texas participants were using their preferred contraceptive method compared to 51% of Californians. After multivariable adjustments, Texas participants had lower odds of using their preferred method (adjusted odds ratio = 0.62, 95% confidence interval = 0.48-0.81) compared to those in California. Texas participants in all insurance categories had a lower predicted probability of preferred method use compared to California participants. In Texas, we found a 12.1 percentage-point difference in the predicted probability of preferred method use between the uninsured (27.5%) and insured (39.6%) (p<0.001). Texans reported financial barriers to using their preferred method more often than Californians (36.7% vs. 19.2%, p<0.001) as did the uninsured compared to the insured (50.9% vs. 18.7%, p<0.001). CONCLUSION These findings present new evidence that state of residence plays an important role in young people's ability to realize their contraceptive preference. Young people in Texas, with lower insurance coverage and more limited access to safety net programs for contraceptive care than in California, have lower use of preferred contraception. It has become urgent in states with abortion bans to support young people's access to their preferred methods.
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Affiliation(s)
- Kristine Hopkins
- Population Research Center, The University of Texas at Austin, Austin, Texas, United States of America
| | - Jennifer Yarger
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, United States of America
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, California, United States of America
| | - Irene Rossetto
- Population Research Center, The University of Texas at Austin, Austin, Texas, United States of America
| | - Audrey Sanchez
- Population Research Center, The University of Texas at Austin, Austin, Texas, United States of America
| | - Elisa Brown
- Department of Obstetrics and Gynecology, Texas Tech University Health Sciences Center, Odessa, Texas, United States of America
| | - Sarah Elmes
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, California, United States of America
| | - Thaddeus Mantaro
- Health Services and Promotion, Dallas College, Dallas, Texas, United States of America
| | - Kari White
- Population Research Center, The University of Texas at Austin, Austin, Texas, United States of America
- Steve Hicks School of Social Work, The University of Texas at Austin, Austin, Texas, United States of America
| | - Cynthia C. Harper
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, California, United States of America
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El Ayadi AM, Nalubwama H, Painter C, Kakaire O, Miller S, Barageine J, Byamugisha J, Obore S, Korn A, Harper CC. Contraceptive preferences and adoption following female genital fistula surgery in Uganda: a mixed-methods study. Reprod Health 2023; 20:121. [PMID: 37598146 PMCID: PMC10439586 DOI: 10.1186/s12978-023-01663-3] [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: 01/14/2023] [Accepted: 08/07/2023] [Indexed: 08/21/2023] Open
Abstract
BACKGROUND Female genital fistula, largely caused by prolonged obstructed labour, is treated by surgical repair. Preventing pregnancy for a minimum period post-repair is recommended to ensure adequate healing and optimize post-repair outcomes. METHODS We examined contraceptive preferences and use among Ugandan fistula patients (n = 60) in the year following genital fistula surgery using mixed-methods. Sexual activity, contraceptive use and pregnancy status were recorded quarterly for 12 months after surgery. In-depth interviews among purposively selected participants (n = 30) explored intimate relationships, sexual experiences, reproductive intentions, and contraceptive use. RESULTS Median participant age was 28 years and almost half (48%) were married or living with partners. Counselling was provided to 97% of participants on delaying sexual intercourse, but only 59% received counselling on contraception. Sexual activity was reported by 32% after 6 months and 50% after 12 months. Eighty-three percent reported not trying for pregnancy. Among sexually active participants, contraceptive use was low at baseline (36%) but increased to 73% at 12 months. Six (10%) women became pregnant including two within 3 months post-repair. Interview participants who desired children immediately were young, had fewer children, experienced stillbirth at fistula development, and felt pressure from partners. Women adopted contraception to fully recover from fistula surgery and avoid adverse outcomes. Others simply preferred to delay childbearing. Reasons cited for not adopting contraception included misconceptions related to their fertility and to contraceptive methods and insufficient or unclear healthcare provider advice on their preferred methods. CONCLUSIONS A high proportion of patients were not counselled by healthcare providers on contraception. Provision of comprehensive patient-centred contraceptive counselling at the time of fistula surgery and beyond is important for patients to optimize healing from fistula and minimize recurrence, as well as to meet their own reproductive preferences.
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Affiliation(s)
- Alison M El Ayadi
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, 550 16th Street, 3rd Floor, San Francisco, CA, 94518, USA.
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, USA.
| | - Hadija Nalubwama
- Department of Obstetrics and Gynaecology, Makerere University College of Health Sciences, Kampala, Uganda
| | - Caitlyn Painter
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, 550 16th Street, 3rd Floor, San Francisco, CA, 94518, USA
| | - Othman Kakaire
- Department of Obstetrics and Gynaecology, Makerere University College of Health Sciences, Kampala, Uganda
| | - Suellen Miller
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, 550 16th Street, 3rd Floor, San Francisco, CA, 94518, USA
| | - Justus Barageine
- Department of Obstetrics and Gynaecology, Makerere University College of Health Sciences, Kampala, Uganda
| | - Josaphat Byamugisha
- Department of Obstetrics and Gynaecology, Makerere University College of Health Sciences, Kampala, Uganda
| | - Susan Obore
- Urogynaecology Division, Mulago National Teaching and Referral Hospital, Kampala, Uganda
| | - Abner Korn
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, 550 16th Street, 3rd Floor, San Francisco, CA, 94518, USA
| | - Cynthia C Harper
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, 550 16th Street, 3rd Floor, San Francisco, CA, 94518, USA
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Rao L, Rocca CH, Muñoz I, Chambers BD, Devaskar S, Asiodu IV, Stern L, Blum M, Comfort AB, Harper CC. "She should support me, she's my doctor:" Patient perceptions of agency in contraceptive decision-making in the clinical encounter in Northern California. Perspect Sex Reprod Health 2023; 55:94-103. [PMID: 37216964 PMCID: PMC10537387 DOI: 10.1363/psrh.12226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
INTRODUCTION Agency in contraceptive decision-making is an essential aspect of reproductive autonomy. We conducted qualitative research to investigate what agency means to patients seeking contraceptive care to inform the development of a validated measure of this construct. METHODOLOGY We held four focus group discussions and seven interviews with sexually-active individuals assigned female at birth, ages 16-29 years, recruited from reproductive health clinics in Northern California. We explored experiences in contraceptive decision-making during the clinic visit. We coded data in ATLAS.ti and by hand, compared codes across three coders, and used thematic analysis to identify salient themes. RESULTS The sample mean age was 21 years, with 17% of participants identifying as Asian, 23% as Black, 27% as Latinx, 17% as Multiracial/other, and 27% as white. Overall, participants reported active and engaged decision-making in their recent contraceptive visit but noted experiences that had undermined their agency in the past. They described how non-judgmental care allowed them to communicate openly, affirming their ability to make their own decisions. However, several mentioned how unexpected contraceptive side effects after the visit had reduced their sense of agency over their decision in retrospect. Several participants, including those who identified as Black, Latinx, and/or Asian, described prior experiences where pressure to use a contraceptive method had undermined their agency and where they had switched providers to regain agency over their contraceptive decisions. DISCUSSION Most participants were aware of their agency during contraceptive visits and how it varied in different experiences with providers and the healthcare system. Patient perspectives can help to inform measurement development and ultimately the delivery of care that supports contraceptive agency.
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Affiliation(s)
- Lavanya Rao
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, School of Medicine, San Francisco, California, USA
| | - Corinne H. Rocca
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, School of Medicine, San Francisco, California, USA
- Advancing New Standards in Reproductive Health (ANSIRH), University of California, San Francisco, School of Medicine, San Francisco, California, USA
| | - Isabel Muñoz
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, School of Medicine, San Francisco, California, USA
- Advancing New Standards in Reproductive Health (ANSIRH), University of California, San Francisco, School of Medicine, San Francisco, California, USA
| | - Brittany D. Chambers
- Department of Human Ecology, University of California, Davis, School of Agricultural and Environmental Sciences, Davis, California, USA
| | - Sangita Devaskar
- Planned Parenthood Northern California, Santa Rosa, California, USA
| | - Ifeyinwa V. Asiodu
- Department of Family Health Care Nursing, School of Nursing, University of California, San Francisco, San Francisco, California, USA
| | - Lisa Stern
- Coalition to Expand Contraceptive Access (CECA), San Francisco, California, USA
| | - Maya Blum
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, School of Medicine, San Francisco, California, USA
| | - Alison B. Comfort
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, School of Medicine, San Francisco, California, USA
| | - Cynthia C. Harper
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, School of Medicine, San Francisco, California, USA
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Harper CC, Jones E, Brindis CD, Watson A, Schroeder R, Boyer CB, Edelman A, Trieu S, Yarger J. Educational Intervention Among Adolescents and Young Adults on Emergency Contraception Options. J Adolesc Health 2023; 72:993-996. [PMID: 36894464 DOI: 10.1016/j.jadohealth.2023.01.007] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 12/15/2022] [Accepted: 01/04/2023] [Indexed: 03/11/2023]
Abstract
PURPOSE Emergency contraception (EC), the 'last chance' contraceptive method, has gained significance post-Roe, but most young people do not know their options. METHODS We conducted an educational intervention on EC among 1,053 students aged 18-25 years. We assessed changes in knowledge of key aspects of EC using generalized estimating equations. RESULTS At baseline, virtually no one was aware of the intrauterine device for EC (4%), but postintervention, 89% correctly identified intrauterine devices as the most effective EC (adjusted odds ratio [aOR] = 116.6; 95% confidence interval [CI] 62.4, 217.8). Knowledge that levonorgestrel pills could be accessed without a prescription grew (60%-90%; aOR = 9.7, 95% CI 6.7-14.0), as did knowledge that pills work best when taken as soon as possible (75%-95%; aOR = 9.6, 95% CI 6.1-14.9). Multivariate results showed adolescent and young adult participants absorbed these key concepts across age, gender, and sexual orientation. DISCUSSION Timely interventions are needed to empower youth with knowledge of EC options.
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Affiliation(s)
- Cynthia C Harper
- Department of Obstetrics, Gynecology and Reproductive Sciences, Bixby Center for Global Reproductive Health, University of California, California, San Francisco; Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, California, San Francisco.
| | - Erin Jones
- University of Southern California Keck School of Medicine, Los Angeles, California
| | - Claire D Brindis
- Department of Obstetrics, Gynecology and Reproductive Sciences, Bixby Center for Global Reproductive Health, University of California, California, San Francisco; Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, California, San Francisco; Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California San Francisco, California, San Francisco
| | - Annalisa Watson
- Department of Obstetrics, Gynecology and Reproductive Sciences, Bixby Center for Global Reproductive Health, University of California, California, San Francisco
| | - Rosalyn Schroeder
- Department of Obstetrics, Gynecology and Reproductive Sciences, Bixby Center for Global Reproductive Health, University of California, California, San Francisco
| | - Cherrie B Boyer
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California San Francisco, California, San Francisco
| | - Alison Edelman
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon
| | - Sang Trieu
- Student Health Center, Ohlone College, Fremont, California
| | - Jennifer Yarger
- Department of Obstetrics, Gynecology and Reproductive Sciences, Bixby Center for Global Reproductive Health, University of California, California, San Francisco; Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, California, San Francisco
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Zuniga C, Blanchard K, Harper CC, Wollum A, Key K, Henderson JT. Effectiveness and efficacy rates of progestin-only pills: A comprehensive literature review. Contraception 2023; 119:109925. [PMID: 36535414 DOI: 10.1016/j.contraception.2022.109925] [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: 10/12/2022] [Revised: 12/02/2022] [Accepted: 12/07/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVES To synthesize published literature on POP effectiveness and efficacy. STUDY DESIGN We searched PubMed Central, PubMed, and the Cochrane library through March 07, 2022. We included articles written in English reporting a Pearl Index or life table rate for pregnancy. We excluded articles only assessing formulations that: were never marketed globally, are only sold in combination with estrogen, are currently sold only for noncontraceptive purposes, or were not given to participants continuously. Four researchers independently extracted data and two analyzed data using Excel and R. RESULTS We included 54 studies. Among studies at low or moderate risk of bias, the median Pearl Index rate (the failure rate during typical use) was 1.63 (range 0.00-14.20, IQR 4.03) and the median method failure Pearl Index rate (the failure rate during perfect use) was 0.97 (range 0.40-6.50, IQR 0.68). Excluding the newer formulations, Desogestrel and Drospirenone, which are closer to combined oral contraceptives in that they prevent pregnancy by inhibiting ovulation, the median Pearl Index rate is 2.00 (range 0.00-14.12, IQR 2.5) and the median method failure Pearl Index rate is 1.05 (range 0.00-10.90, IQR 1.38). CONCLUSIONS Among studies at low or moderate risk of bias, the median Pearl Index rate during typical POP use was much lower than currently estimated (7.00), while the median perfect use rate was similar to current estimates. IMPLICATIONS Future research should investigate the possibility that POPs may be much more effective during typical use than currently believed.
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Affiliation(s)
| | | | - Cynthia C Harper
- Obstetrics, Gynecology and Reproductive Sciences, Bixby Center for Global Reproductive Health, University of California, San Francisco, CA, United States
| | | | - Katherine Key
- Ibis Reproductive Health, Cambridge, MA, United States
| | - Jillian T Henderson
- Kaiser Permanente, Northwest, Center for Health Research, Portland, OR, United States
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11
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Yarger J, Hopkins K, Elmes S, Rossetto I, De La Melena S, McCulloch CE, White K, Harper CC. Perceived Access to Contraception via Telemedicine Among Young Adults: Inequities by Food and Housing Insecurity. J Gen Intern Med 2023; 38:302-308. [PMID: 35657468 PMCID: PMC9165539 DOI: 10.1007/s11606-022-07669-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 05/06/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Telemedicine expanded rapidly during the COVID-19 pandemic, including for contraceptive services. Data are needed to understand whether young people can access telemedicine for contraception, especially in underserved populations. OBJECTIVE To compare young people's perceived access to telemedicine visits for contraception during the COVID-19 pandemic by food and housing insecurity. DESIGN Supplementary study to a cluster randomized controlled trial in 25 community colleges in California and Texas. Online surveys were administered May 2020 to April 2021. Mixed-effects logistic regression models with random effects for site were used to examine differences in access to contraception through telemedicine by food and housing insecurity status, controlling for key sociodemographic characteristics, including race/ethnicity, non-English primary language, health insurance status, and state of residence, and contraceptive method used. PARTICIPANTS 1,414 individuals assigned female at birth aged 18-28. MAIN MEASURES Survey measures were used to capture how difficult it would be for a participant to have a telemedicine visit (phone or video) for contraception. KEY RESULTS Twenty-nine percent of participants were food insecure, and 15% were housing insecure. Nearly a quarter (24%) stated that it would be difficult to have a phone or video visit for contraception. After accounting for sociodemographic factors and type of method used, food insecure (adjusted odds ratio [aOR], 2.17; 95% confidence interval [CI], 1.62-2.91) and housing insecure (aOR, 1.62; 95% CI, 1.13-2.33) participants were significantly more likely to report that it would be difficult to use telemedicine for contraception during the pandemic. CONCLUSIONS Underserved patients are those who could benefit most from the expansion of telemedicine services, yet our findings show that young people experiencing basic needs insecurity perceive the greatest difficulty accessing these services for essential reproductive care. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03519685.
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Affiliation(s)
- Jennifer Yarger
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, 550 16th Street, San Francisco, CA, 94158, USA.
| | - Kristine Hopkins
- Population Research Center, University of Texas at Austin, Austin, TX, USA
| | - Sarah Elmes
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, 550 16th Street, San Francisco, CA, 94158, USA
| | - Irene Rossetto
- Population Research Center, University of Texas at Austin, Austin, TX, USA
| | - Stephanie De La Melena
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, 550 16th Street, San Francisco, CA, 94158, USA
| | - Charles E McCulloch
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | - Kari White
- Population Research Center, University of Texas at Austin, Austin, TX, USA
| | - Cynthia C Harper
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, 550 16th Street, San Francisco, CA, 94158, USA
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12
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Yarger J, Elmes S, Rossetto I, Hopkins K, Van Liefde D, Marquez L, Harper CC. P078Use of direct-to-consumer telemedicine companies for contraception among young adults. Contraception 2022. [DOI: 10.1016/j.contraception.2022.09.102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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13
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Comfort AB, El Ayadi AM, Camlin CS, Tsai AC, Nalubwama H, Byamugisha J, Walker DM, Moody J, Roberts T, Senoga U, Krezanoski PJ, Harper CC. The role of informational support from women's social networks on antenatal care initiation: qualitative evidence from pregnant women in Uganda. BMC Pregnancy Childbirth 2022; 22:708. [PMID: 36114484 PMCID: PMC9479405 DOI: 10.1186/s12884-022-05030-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 08/29/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Early and appropriate use of antenatal care services is critical for reducing maternal and neonatal mortality and morbidity. Yet most women in sub-Saharan Africa, including Uganda, do not seek antenatal care until later during pregnancy. This qualitative study explored pregnant women's reliance on social ties for information about initiation of antenatal care. METHODS We conducted semi-structured, in-depth interviews with 30 pregnant women seeking their first antenatal care visit at Kawempe Referral Hospital in Kampala, Uganda. Recruitment was done purposively to obtain variation by parity and whether women currently had a male partner. Study recruitment occurred from August 25th 2020 - October 26th, 2020. We used thematic analysis following a two-stage coding process, with both deductive and inductive codes. Deductive codes followed the key domains of social network and social support theory. RESULTS We found that the most important source of information about antenatal care initiation was these women's mothers. Other sources included their mothers-in-law, female elders including grandmothers, and male partners. Sisters and female friends were less influential information sources about antenatal initiation. One of the primary reasons for relying on their own mothers, mothers-in-law, and elder women was due to these women's lived experience with pregnancy and childbirth. Trust in the relationship was also an important factor. Some pregnant women were less likely to rely on their sisters or female friends, either due to lack of trust or these women's lack of experience with pregnancy and childbirth. The advice that pregnant women received from their mothers and others on the ideal timing for antenatal care initiation varied significantly, including examples of misinformation about when to initiate antenatal care. Pregnant women seemed less likely to delay care when more than one social tie encouraged early antenatal care. CONCLUSIONS Educating women's social networks, especially their mothers, mothers-in-law, and community elders, about the importance of early antenatal care initiation is a promising avenue for encouraging pregnant women to seek care earlier in pregnancy.
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Affiliation(s)
- Alison B. Comfort
- grid.266102.10000 0001 2297 6811Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, 550 16th Street, San Francisco, CA 94143 USA
| | - Alison M. El Ayadi
- grid.266102.10000 0001 2297 6811Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, 550 16th Street, San Francisco, CA 94143 USA
| | - Carol S. Camlin
- grid.266102.10000 0001 2297 6811Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, 1330 Broadway, Suite 1100, Oakland, CA 94612 USA
| | - Alexander C. Tsai
- grid.38142.3c000000041936754XCenter for Global Health and Mongan Institute, Massachusetts General Hospital, Harvard Medical School, 125 Nashua Street, Suite 722, Boston, MA 02114 USA
| | - Hadija Nalubwama
- grid.11194.3c0000 0004 0620 0548College of Health Sciences, School of Medicine, Makerere University, PO Box 7072, Kampala, Uganda
| | - Josaphat Byamugisha
- grid.11194.3c0000 0004 0620 0548College of Health Sciences, School of Medicine, Makerere University, PO Box 7072, Kampala, Uganda
| | - Dilys M. Walker
- grid.266102.10000 0001 2297 6811Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, 550 16th Street, San Francisco, CA 94143 USA
| | - James Moody
- grid.26009.3d0000 0004 1936 7961Duke University, 268 Soc/Psych Building, Durham, NC 27708-0088 USA
| | - Tatyana Roberts
- grid.266102.10000 0001 2297 6811Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, 550 16th Street, San Francisco, CA 94143 USA
| | - Umar Senoga
- grid.11194.3c0000 0004 0620 0548College of Health Sciences, School of Medicine, Makerere University, PO Box 7072, Kampala, Uganda
| | - Paul J. Krezanoski
- grid.266102.10000 0001 2297 6811University of California San Francisco, Zuckerberg San Francisco General Hospital, 1001 Potrero Ave, San Francisco, CA 94110 USA
| | - Cynthia C. Harper
- grid.266102.10000 0001 2297 6811Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, 550 16th Street, San Francisco, CA 94143 USA
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Sebastian RA, Robinson J, Rayburn E, White A, Andersen AM, Cantu I, Harper CC, Goodman S, Kong AS, Jimenez EY. Virtual Intrauterine Device Placement Training Improves Clinician Comfort. Fam Med 2022; 54:456-460. [DOI: 10.22454/fammed.2022.635704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Background and Objectives: Virtual intrauterine device (IUD) training options can improve clinician continuing education and patient IUD access. Our objective was to evaluate a virtual, hands-on IUD training for primary care clinicians.
Methods: Training sessions occurred via video conferencing and included didactic instruction on IUD eligibility, counseling, placement, and removal. Trainers used pelvic models to demonstrate procedures for all Food and Drug Administration-approved IUDs and guided trainees during hands-on practice with IUDs. Surveys administered before and immediately after training assessed clinician satisfaction and evaluated pre-to-posttraining changes in self-rated comfort level with IUD procedures. We evaluated the changes using Wilcoxon signed-rank sum tests.
Results: Thirty-four New Mexico clinicians were trained during 29 sessions from January-June 2021. Trainees (n=32 responding to pre/postsurveys) included nurse practitioners and midwives (48%), physician assistants (28%), physicians (17%), and clinicians in training (7%). Approximately one-third (37%) had previous experience placing IUDs. Elements of training delivery were highly rated by clinicians, with all trainees successfully using the virtual platform and half indicating that they would potentially choose a virtual training over an in-person option in the future. After the training, clinicians reported significantly increased comfort with all aspects of IUD placement and removal (P≤.01).
Conclusions: An interactive, virtual IUD training model was highly rated among practicing clinicians and increased their comfort with IUD placement and removal.
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Affiliation(s)
- Rachel A. Sebastian
- Long-Acting Reversible Contraceptive Mentoring Program, Division of Adolescent Medicine, Department of Pediatrics, University of New Mexico Health Sciences Center, Albuquerque, NM
| | - Jennifer Robinson
- Long-Acting Reversible Contraceptive Mentoring Program, Division of Adolescent Medicine, Department of Pediatrics, University of New Mexico Health Sciences Center, Albuquerque, NM
- Beyond the Pill, Bixby Center for Global Reproductive Health, University of California – San Francisco, San Francisco, CA
| | - Erin Rayburn
- Long-Acting Reversible Contraceptive Mentoring Program, Division of Adolescent Medicine, Department of Pediatrics, University of New Mexico Health Sciences Center, Albuquerque, NM
| | - Anna White
- Long-Acting Reversible Contraceptive Mentoring Program, Division of Adolescent Medicine, Department of Pediatrics, University of New Mexico Health Sciences Center, Albuquerque, NM
| | - Andrea M. Andersen
- Long-Acting Reversible Contraceptive Mentoring Program, Division of Adolescent Medicine, Department of Pediatrics, University of New Mexico Health Sciences Center, Albuquerque, NM
| | - Irene Cantu
- Long-Acting Reversible Contraceptive Mentoring Program, Division of Adolescent Medicine, Department of Pediatrics, University of New Mexico Health Sciences Center, Albuquerque, NM
| | - Cynthia C. Harper
- Beyond the Pill, Bixby Center for Global Reproductive Health, University of California – San Francisco, San Francisco, CA
| | - Susan Goodman
- Beyond the Pill, Bixby Center for Global Reproductive Health, University of California – San Francisco, San Francisco, CA
| | - Alberta S. Kong
- Long-Acting Reversible Contraceptive Mentoring Program, Division of Adolescent Medicine, Department of Pediatrics, University of New Mexico Health Sciences Center, Albuquerque, NM
| | - Elizabeth Yakes Jimenez
- Long-Acting Reversible Contraceptive Mentoring Program, Division of Adolescent Medicine, Department of Pediatrics, University of New Mexico Health Sciences Center, Albuquerque, NM
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15
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Rao L, Comfort AB, Dojiri SS, Goodman S, Yarger J, Shah N, Folse C, Blum M, Hankin J, Harper CC. Telehealth for Contraceptive Services During the COVID-19 Pandemic: Provider Perspectives. Womens Health Issues 2022; 32:477-483. [PMID: 35691762 PMCID: PMC9110325 DOI: 10.1016/j.whi.2022.05.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 05/02/2022] [Accepted: 05/10/2022] [Indexed: 12/04/2022]
Abstract
Background Telehealth use rapidly increased during the COVID-19 pandemic, including for contraceptive care (e.g., counseling and method provision). This study explored providers’ experiences with contraceptive care via telehealth. Methods We conducted a survey with open-ended responses among contraceptive providers across the United States. The study population included physicians, nurse practitioners, health educators, and other health professionals (n = 546). Data were collected from April 10, 2020, to January 29, 2021. We conducted qualitative content analysis of the open-ended responses. Results Providers highlighted the benefits of telehealth, including continuing access to contraceptive services and accommodating patients who faced challenges attending in-person contraceptive visits. Providers at school-based health centers reported telehealth allowed them to reach young people while schools were closed. However, many providers noted a lack of patient awareness about the availability of telehealth services and disparities in access to technology. Providers felt there was less personal connection in virtual contraceptive counseling, noted challenges with confidentiality, and expressed concern about the inability to provide the full range of contraceptive methods through telehealth alone. Conclusions The pandemic significantly impacted contraceptive health care delivery. Telehealth has sustained access to contraception in important ways, but has been accompanied by various challenges, including technological access and confidentiality. As hybrid models of care evolve, it is important to assess how telehealth can play a role in providing contraceptive care while addressing its barriers.
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Affiliation(s)
- Lavanya Rao
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco School of Medicine, San Francisco, California.
| | - Alison B Comfort
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco School of Medicine, San Francisco, California
| | - S Sei Dojiri
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco School of Medicine, San Francisco, California
| | - Suzan Goodman
- Department of Family and Community Medicine, University of California, San Francisco School of Medicine, San Francisco, California
| | - Jennifer Yarger
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco School of Medicine, San Francisco, California
| | - Nishant Shah
- Planned Parenthood of Maryland, Inc., Annapolis, Maryland
| | - Connie Folse
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco School of Medicine, San Francisco, California
| | - Maya Blum
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco School of Medicine, San Francisco, California
| | - Julia Hankin
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco School of Medicine, San Francisco, California
| | - Cynthia C Harper
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco School of Medicine, San Francisco, California
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16
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Comfort AB, Rao L, Goodman S, Raine-Bennett T, Barney A, Mengesha B, Harper CC. Assessing differences in contraceptive provision through telemedicine among reproductive health providers during the COVID-19 pandemic in the United States. Reprod Health 2022; 19:99. [PMID: 35459218 PMCID: PMC9026031 DOI: 10.1186/s12978-022-01388-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [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: 11/12/2021] [Accepted: 03/17/2022] [Indexed: 11/10/2022] Open
Abstract
Background Providers faced challenges in maintaining patient access to contraceptive services and public health safety during the COVID-19 pandemic. Due to increased barriers to care, providers increasingly used telemedicine for contraceptive care, curbside services, mail-order pharmacies, and on-line or home delivery of contraceptive methods, including self-administration of subcutaneous depo medroxyprogesterone acetate (DMPA-SQ). To better understand how reproductive health providers adapted service provision during the pandemic, this study assessed clinical practice changes and strategies providers adopted throughout the United States to maintain contraceptive care, particularly when clinics closed on-site, and the challenges that remained in offering contraceptive services, especially to marginalized patient populations. Methods We surveyed U.S. providers and clinic staff (n = 907) in April 2020–January 2021, collecting data on contraceptive service delivery challenges and adaptations, including telemedicine. We assessed clinical practice changes with multivariate regression analyses using generalized linear models with a Poisson distribution and cluster robust standard errors, adjusting for clinic patient volume, practice setting, region, Title X funding, and time of survey. Results While 80% of providers reported their clinic remained open, 20% were closed on-site. Providers said the pandemic made it more difficult to offer the full range of contraceptive methods (65%), contraceptive counseling (61%) or to meet the needs of patients in marginalized communities (50%). While only 11% of providers offered telemedicine pre-pandemic, most offered telemedicine visits (79%) during the pandemic. Some used mail-order pharmacies (35%), curbside contraceptive services (22%), and DMPA-SQ for self-administration (10%). Clinics that closed on-site were more likely to use mail-order pharmacies (aRR 1.83, 95% CI [1.37–2.44]) and prescribe self-administered DMPA-SQ (aRR 3.85, 95% CI [2.40–6.18]). Clinics closed on-site were just as likely to use telemedicine as those that remained open. Among clinics using telemedicine, those closed on-site continued facing challenges in contraceptive service provision. Conclusions Clinics closing on-site were just as likely to offer telemedicine, but faced greater challenges in offering contraceptive counseling and the full range of contraceptive methods, and meeting the needs of marginalized communities. Maintaining in-person care for contraceptive services, in spite of staffing shortages and financial difficulties, is an important objective during and beyond the pandemic. Providers faced challenges in maintaining patient access to contraceptive services and public health safety during the COVID-19 pandemic. Due to increased barriers to care, providers increasingly used telemedicine for contraceptive care as well as using curbside services, mail-order pharmacies, and on-line or home delivery of contraceptive methods, including self-administration of subcutaneous depo medroxyprogesterone acetate (DMPA-SQ). This study examined use of telemedicine and other clinical practice changes among U.S. contraceptive providers during the COVID-19 pandemic. We surveyed providers (n=907) in April 2020–January 2021, collecting data on contraceptive service delivery challenges and adaptations, including telemedicine. Our analyses showed that, in response to the pandemic, many clinics adopted telemedicine to offer contraceptive services. Furthermore, clinics that were closed on-site were just as likely to start offering telemedicine visits during the pandemic as those that remained open. Despite these adaptions, clinics still faced challenges in offering the full range of contraceptive methods, providing contraceptive counseling, and meeting the needs of patients in marginalized communities. Offering telemedicine visits during the pandemic did not reduce the challenges in offering contraceptive services. Few studies have focused on providers and the clinical practice changes they rapidly achieved to maintain contraceptive access for their patients during the pandemic. Our results highlighted that telemedicine should be considered as a complement to on-site care because of the challenges in providing full services without in-person visits. Maintaining in-person care for contraceptive services, in spite of staffing shortages and financial difficulties, is an important objective during and beyond the pandemic.
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Affiliation(s)
- Alison B Comfort
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Bixby Center for Global Reproductive Health, University of California San Francisco, 550 16th Street, 3rd floor, San Francisco, CA, 94143, USA.
| | - Lavanya Rao
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Bixby Center for Global Reproductive Health, University of California San Francisco, 550 16th Street, 3rd floor, San Francisco, CA, 94143, USA.,Deloitte, Portland, OR, USA
| | - Suzan Goodman
- Department of Family and Community Medicine, Bixby Center for Global Reproductive Health, University of California San Francisco, San Francisco, CA, USA
| | - Tina Raine-Bennett
- Division of Research, Kaiser Permanente, Oakland, CA, USA.,Medicines360, San Francisco, CA, USA
| | - Angela Barney
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA
| | - Biftu Mengesha
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Bixby Center for Global Reproductive Health, University of California San Francisco, 550 16th Street, 3rd floor, San Francisco, CA, 94143, USA
| | - Cynthia C Harper
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Bixby Center for Global Reproductive Health, University of California San Francisco, 550 16th Street, 3rd floor, San Francisco, CA, 94143, USA
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Holt HK, Sawaya GF, El Ayadi AM, Henderson JT, Rocca CH, Westhoff CL, Harper CC. Delayed Visits for Contraception Due to Concerns Regarding Pelvic Examination Among Women with History of Intimate Partner Violence. J Gen Intern Med 2021; 36:1883-1889. [PMID: 33145695 PMCID: PMC8298732 DOI: 10.1007/s11606-020-06334-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Accepted: 10/21/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Concern regarding pelvic examinations may be more common among women experiencing intimate partner violence. OBJECTIVE We examined women's attitudes towards pelvic examination with history of intimate partner violence (pressured to have sex, or verbal, or physical abuse). DESIGN Secondary analysis of data from a cluster randomized trial on contraceptive access. PARTICIPANTS Women aged 18-25 were recruited at 40 reproductive health centers across the USA (2011-2013). MAIN MEASURES Delays in clinic visits for contraception and preference to avoid pelvic examinations, by history of ever experiencing pressured sex, verbal, or physical abuse from a sexual partner, reported by frequency (never, rarely, sometimes, often). We used multivariable logistic regression with generalized estimating equations for clustered data. KEY RESULTS A total of 1490 women were included. Ever experiencing pressured sex was reported by 32.4% of participants, with 16.5% reporting it rarely, 12.1% reporting it sometimes, and 3.8% reporting it often. Ever experiencing verbal abuse was reported by 19.4% and physical abuse by 10.2% of participants. Overall, 13.2% of participants reported ever having delayed going to the clinic for contraception to avoid having a pelvic examination, and 38.2% reported a preference to avoid pelvic examinations. In multivariable analysis, women reporting that they experienced pressured sex often had significantly higher odds of delaying a clinic visit for birth control (aOR 3.10 95% CI 1.39-6.84) and for reporting a preference to avoid pelvic examinations (aOR 2.91 95% CI 1.57-5.40). We found no associations between delay of clinic visits or preferences to avoid a pelvic examination and verbal or physical abuse. CONCLUSIONS History of pressured sex from an intimate partner is common. Among women who have experienced pressured sex, concern regarding pelvic examinations is a potential barrier to contraception. Communicating that routine pelvic examinations are no longer recommended by professional societies could potentially reduce barriers and increase preventive healthcare visits.
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Affiliation(s)
- Hunter K Holt
- Department of Family and Community Medicine, University of California, San Francisco, CA, USA.
| | - George F Sawaya
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, CA, USA
| | - Alison M El Ayadi
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, CA, USA
| | - Jillian T Henderson
- Kaiser Permanente Center for Health Research, Northwest, Portland, Oregon, USA
| | - Corinne H Rocca
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, CA, USA
| | - Carolyn L Westhoff
- Department of Obstetrics and Gynecology, Columbia University Medical Center, New York, NY, USA
| | - Cynthia C Harper
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, CA, USA
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Yarger J, Schroeder R, Cabral MA, Lamme JS, McCulloch CE, Trieu SL, de Jounge A, Harper CC. An Educational Intervention to Raise Awareness of Contraceptive Options Among Young People. J Womens Health (Larchmt) 2021; 31:252-260. [PMID: 34101500 DOI: 10.1089/jwh.2020.8753] [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] [Indexed: 11/13/2022] Open
Abstract
Background: Young people in the United States know little about contraceptive options available to them, although method use is sensitive to individual preferences, and method switching is common. For young people to gain reproductive autonomy, a first step is to be aware of different contraceptives, including hormonal and nonhormonal methods. We tested whether an educational intervention delivered on community college campuses was effective in increasing contraceptive awareness. Materials and Methods: We developed a low-cost educational intervention featuring youth-friendly visual tools and tested its impact on method awareness and knowledge among 1,051 students of all genders, aged 18-25 years, at five community colleges. We used generalized estimating equations to test changes in awareness of a range of methods, including male and female (internal) condoms, the pill, patch, vaginal ring, shot, intrauterine devices, implant, and emergency contraception. Results: Over 90% of participants were aware of male condoms and the pill at baseline, but fewer had heard of other options (ranging from 31% to 76% for different methods). Across all methods, awareness increased to a mean of 88% among female participants and 82% among male participants postintervention. Awareness of the full range of methods increased from 31% to 55% (adjusted odds ratio [aOR]: 4.4, 95% confidence interval [CI]: 3.1-6.2]) among female participants and 11% to 36% (aOR: 10.8, 95% CI: 5.3-21.8) among male participants postintervention. The intervention was similarly effective by sexual orientation, race/ethnicity, nativity, or insurance coverage. Conclusion: This educational intervention significantly improved all students' awareness of a range of contraceptives, supporting one important aspect of reproductive health for young people in community settings.
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Affiliation(s)
- Jennifer Yarger
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, School of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Rosalyn Schroeder
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, School of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Marta A Cabral
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, School of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Jacqueline S Lamme
- Department of Obstetrics and Gynecology, U.S. Naval Hospital Bremerton, Bremerton, Washington, USA
| | - Charles E McCulloch
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, USA
| | - Sang Leng Trieu
- Student Health Center, Ohlone College, Fremont, California, USA
| | | | - Cynthia C Harper
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, School of Medicine, University of California, San Francisco, San Francisco, California, USA
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El Ayadi AM, Rocca CH, Averbach SH, Goodman S, Darney PD, Patel A, Harper CC. Intrauterine Devices and Sexually Transmitted Infection among Older Adolescents and Young Adults in a Cluster Randomized Trial. J Pediatr Adolesc Gynecol 2021; 34:355-361. [PMID: 33276125 PMCID: PMC8096684 DOI: 10.1016/j.jpag.2020.11.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 11/23/2020] [Accepted: 11/25/2020] [Indexed: 11/18/2022]
Abstract
STUDY OBJECTIVE Provider misconceptions regarding intrauterine device (IUD) safety for adolescents and young women can unnecessarily limit contraceptive options offered; we sought to evaluate rates of Neisseria gonorrhoeae or Chlamydia trachomatis (GC/CT) diagnoses among young women who adopted IUDs. DESIGN Secondary analysis of a cluster-randomized provider educational trial. SETTING Forty US-based reproductive health centers. PARTICIPANTS We followed 1350 participants for 12 months aged 18-25 years who sought contraceptive care. INTERVENTIONS The parent study assessed the effect of provider training on evidence-based contraceptive counseling. MAIN OUTCOME MEASURES We assessed incidence of GC/CT diagnoses according to IUD use and sexually transmitted infection risk factors using Cox regression modeling and generalized estimating equations. RESULTS Two hundred four participants had GC/CT history at baseline; 103 received a new GC/CT diagnosis over the 12-month follow-up period. IUDs were initiated by 194 participants. Incidence of GC/CT diagnosis was 10.0 per 100 person-years during IUD use vs 8.0 otherwise. In adjusted models, IUD use (adjusted hazard ratio [aHR], 1.31; 95% confidence interval [CI], 0.71-2.40), adolescent age (aHR, 1.28; 95% CI, 0.72-2.27), history of GC/CT (aHR, 1.23; 95% CI, 0.75-2.00), and intervention status (aHR, 1.12; 95% CI, 0.74-1.71) were not associated with GC/CT diagnosis; however, new GC/CT diagnosis rates were significantly higher among individuals who reported multiple partners at baseline (aHR, 2.0; 95% CI, 1.34-2.98). CONCLUSION In this young study population with GC/CT history, this use of IUDs was safe and did not lead to increased GC/CT diagnoses. However, results highlighted the importance of dual sexually transmitted infection and pregnancy protection for participants with multiple partners.
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Affiliation(s)
- Alison M El Ayadi
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, California.
| | - Corinne H Rocca
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, California
| | - Sarah H Averbach
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, California; Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Diego, San Diego, California
| | - Suzan Goodman
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, California
| | - Philip D Darney
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, California
| | - Ashlesha Patel
- Planned Parenthood Federation of America, New York, New York
| | - Cynthia C Harper
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, California
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20
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Comfort AB, Harper CC, Tsai AC, Moody J, Perkins JM, Rasolofomana JR, Alperin C, Ranjalahy AN, Heriniaina R, Krezanoski PJ. Social and provider networks and women's contraceptive use: Evidence from Madagascar. Contraception 2021; 104:147-154. [PMID: 33901430 DOI: 10.1016/j.contraception.2021.04.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 04/09/2021] [Accepted: 04/14/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Women may differ by whether they rely on health providers and/or social ties for seeking information and advice about family planning. It is unknown whether these differences matter for contraceptive outcomes. This study assessed the association between women's family planning (FP) network (social and/or provider ties) and contraceptive use. STUDY DESIGN This cross-sectional, egocentric network study was conducted among reproductive-age women (n = 193) in rural Madagascar. Data included socio-demographics and contraceptive use. Respondents listed who they relied on for contraceptive information, advice or guidance and provided ties' gender, age, relationship, and perceived support of contraceptive use. The primary outcome was current contraceptive use. Predictors included having a FP network (0/1) and FP network composition (no network, social ties only, provider ties only, both provider and social ties), respectively. Analyses were conducted using a generalized linear model specifying a Poisson distribution, with covariate adjustment and cluster robust standard errors. RESULTS Having a network of individuals to turn to for contraceptive information compared to having no FP network was positively associated with contraceptive use (adjusted relative risk [aRR] 4.4, 95% confidence interval [CI] 2.00-9.87). Having a social network, a provider network, or a combination of social and provider network were all positively associated with contraceptive use (aRR 4.30 [CI 1.92-9.66], aRR 4.46 [CI 2.04-9.75], aRR 4.72 [CI 1.93-11.50], respectively), compared to having no FP network. CONCLUSIONS Contraceptive use was higher among women who relied on social ties, provider ties or both for contraceptive information and advice, compared to women with no FP network. These findings suggest that FP interventions should use a multicomponent approach taking into account both social and provider networks. IMPLICATIONS It is unknown whether differences in whether women rely on social ties (friends, partner, family members) vs. providers for contraceptive information and advice affect contraceptive outcomes. Women are just as likely to use contraception whether they rely on social ties, provider ties, or both for contraceptive information and advice.
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Affiliation(s)
- Alison B Comfort
- University of California San Francisco, San Francisco, CA, United States; Opportunity Solutions International, San Francisco, CA, United States.
| | - Cynthia C Harper
- University of California San Francisco, San Francisco, CA, United States
| | - Alexander C Tsai
- Center for Global Health and Mongan Institute, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | | | - Jessica M Perkins
- Peabody College of Education and Human Development, Vanderbilt University, Nashville, TN, United States
| | - Justin Ranjalahy Rasolofomana
- Institut National de Santé Publique et Communautaire, Ex-Ecole de Médecine de Befelatanana, Antananarivo, Madagascar
| | - Cora Alperin
- University of Chicago, Chicago, IL, United States
| | | | | | - Paul J Krezanoski
- University of California San Francisco, San Francisco, CA, United States; Opportunity Solutions International, San Francisco, CA, United States
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21
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Comfort AB, Krezanoski PJ, Rao L, El Ayadi A, Tsai AC, Goodman S, Harper CC. Mental health among outpatient reproductive health care providers during the US COVID-19 epidemic. Reprod Health 2021; 18:49. [PMID: 33627155 PMCID: PMC7903398 DOI: 10.1186/s12978-021-01102-1] [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] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 02/09/2021] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION Both inpatient and outpatient providers may be at increased risk of stress, anxiety and depression from their roles as health providers during the COVID-19 epidemic. This study explores how the US COVID-19 epidemic has increased feelings of stress, anxiety and depression among outpatient reproductive health providers. METHODS We conducted a survey with open-ended responses among outpatient reproductive health providers across the U.S. engaged in contraceptive care to collect data on their experiences with stress, anxiety and depression during the COVID-19 epidemic. The study population included physicians, nurses, social workers, and other health professions [n = 288]. Data were collected from April 21st-June 24th 2020. We used content analysis of free text responses among providers reporting increased stress, anxiety or depression. RESULTS Two-thirds (184) of providers reported increased stress and one-third (96) reported increased anxiety or depression related to care provision during the COVID-19 epidemic. The major sources of stress, anxiety and depression were due to patient care, worry about becoming infected or infecting family members, work- and home-related concerns, experiencing provider burnout, and fear of the unknown. Concerns about quality of patient care, providers' changing responsibilities, lack of personal protective equipment, and difficulty coping with co-worker illness and absence all contributed to provider stress and anxiety. Worries about unemployment and childcare responsibilities were also highlighted. Providers attributed their stress, anxiety or depression to feeling overwhelmed, being unable to focus, lacking sleep, and worrying about the unknown. CONCLUSIONS US outpatient providers are experiencing significant stress, anxiety, and depression during the US COVID-19 epidemic. Policy and programmatic responses are urgently needed to address the widespread adverse mental health consequences of this epidemic on outpatient providers, including reproductive health providers, across the US. Both inpatient and outpatient providers may be at increased risk of stress, anxiety and depression from their roles as health providers during the COVID-19 epidemic. This study explores how the US COVID-19 epidemic has increased feelings of stress, anxiety and depression among outpatient reproductive health providers across the US. We conducted a survey from April 21st to June 24th, 2020 among outpatient reproductive health providers, including physicians, nurses, social workers and other health professions. We asked open-ended questions to understand why providers reported increased stress, anxiety and/or depression. Two-thirds (184) of providers reported increased stress and one-third (96) reported increased anxiety or depression from care provision during the COVID-19 epidemic. Major sources of stress, anxiety and depression were due to patient care, worry about becoming infected or infecting family members, work- and home-related concerns, experiencing provider burnout, and fear of the unknown. Concerns about quality of patient care, providers' changing responsibilities, lack of personal protective equipment, and difficulty coping with co-worker illness and absence all contributed to provider stress and anxiety. Worries about unemployment and childcare responsibilities were also highlighted. Providers attributed their stress, anxiety or depression to feeling overwhelmed, being unable to focus, lacking sleep, and worrying about the unknown. This study highlights that US outpatient reproductive health providers are experiencing significant stress, anxiety, and depression during the US COVID-19 epidemic. Policy and programmatic responses are urgently needed to address the widespread adverse mental health consequences of this epidemic on outpatient providers, including reproductive health providers, across the US.
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Affiliation(s)
- Alison B. Comfort
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco, 550 16th Street, 3rd floor, San Francisco, CA 94143 USA
| | - Paul J. Krezanoski
- Department of Medicine, University of California San Francisco, Zuckerberg San Francisco General Hospital, 1001 Potrero Ave, San Francisco, CA 94110 USA
| | - Lavanya Rao
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco, 550 16th Street, 3rd floor, San Francisco, CA 94143 USA
| | - Alison El Ayadi
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco, 550 16th Street, 3rd floor, San Francisco, CA 94143 USA
| | - Alexander C. Tsai
- Massachusetts General Hospital, Harvard Medical School, 125 Nashua Street, Suite 722, Boston, MA 02114 USA
| | - Suzan Goodman
- Bixby Center for Global Reproductive Health, Department of Family and Community Medicine, University of California San Francisco, 550 16th Street, 3rd floor, San Francisco, CA 94143 USA
| | - Cynthia C. Harper
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco, 550 16th Street, 3rd floor, San Francisco, CA 94143 USA
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Comfort AB, Rao L, Goodman S, Barney A, Glymph A, Schroeder R, McCulloch C, Harper CC. Improving Capacity at School-based Health Centers to Offer Adolescents Counseling and Access to Comprehensive Contraceptive Services. J Pediatr Adolesc Gynecol 2021; 34:26-32. [PMID: 32730800 PMCID: PMC7385555 DOI: 10.1016/j.jpag.2020.07.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 07/20/2020] [Indexed: 11/26/2022]
Abstract
STUDY OBJECTIVES Many pediatric providers serving adolescents are not trained to offer comprehensive contraceptive services, including intrauterine devices (IUDs) and implants, despite high safety and satisfaction among adolescents. This study assessed an initiative to train providers at school-based health centers (SBHCs) to offer students the full range of contraceptive methods. DESIGN Surveys were administered at baseline pre-training and at follow-up 3 months post-training. Data were analyzed using generalized estimating equations for clustered data to examine clinical practice changes. SETTING Eleven contraceptive trainings at SBHCs across the United States from 2016-2019. PARTICIPANTS A total of 260 providers from 158 SBHCs serving 135,800 students. INTERVENTIONS On-site training to strengthen patient-centered counseling and to equip practitioners to integrate IUDs and implants into contraceptive services. MAIN OUTCOME MEASURES The outcomes included counseling experience on IUDs and implants, knowledge of patient eligibility, and clinician method skills. RESULTS At follow-up, providers were significantly more likely to report having enough experience to counsel on IUDs (adjusted odds ratio [aOR], 4.08; 95% confidence interval [CI], 2.62-6.36]) and implants (aOR, 3.06; 95% CI, 2.05-4.57). Provider knowledge about patient eligibility for IUDs, including for adolescents, increased (P < .001). Providers were more likely to offer same-visit IUD (aOR, 2.10; 95% CI, 1.41-3.12) and implant services (aOR, 1.66; 95% CI, 1.44-1.91). Clinicians' skills with contraceptive devices improved, including for a newly available low-cost IUD (aOR, 2.21; 95% CI, 1.45-3.36). CONCLUSIONS Offering evidence-based training is a promising approach to increase counseling and access to comprehensive contraceptive services at SBHCs.
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Affiliation(s)
- Alison B Comfort
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, CA.
| | - Lavanya Rao
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, CA
| | - Suzan Goodman
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, CA
| | - Angela Barney
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, CA
| | | | - Rosalyn Schroeder
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, CA
| | - Charles McCulloch
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, CA
| | - Cynthia C Harper
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, CA
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Comfort AB, Harper CC, Tsai AC, Perkins JM, Moody J, Rasolofomana JR, Alperin C, Schultz M, Ranjalahy AN, Heriniaina R, Krezanoski PJ. The association between men's family planning networks and contraceptive use among their female partners: an egocentric network study in Madagascar. BMC Public Health 2021; 21:209. [PMID: 33494746 PMCID: PMC7831255 DOI: 10.1186/s12889-021-10180-6] [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] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 01/06/2021] [Indexed: 01/07/2023] Open
Abstract
Background Ensuring women have information, support and access to family planning (FP) services will allow women to exercise their reproductive autonomy and reduce maternal mortality, which remains high in countries such as Madagascar. Research shows that women’s social networks - their ties with partners, family members, friends, and providers - affect their contraceptive use. Few studies have considered the role of men’s social networks on women’s contraceptive use. Insofar as women’s contraceptive use may be influenced by their male partners, women’s contraceptive use may also be affected by their partner’s social networks. Men may differ by the types of ties they rely on for information and advice about FP. It is unknown whether differences in the composition of men’s FP networks matter for couples’ contraceptive use. This study assessed the association between men’s FP networks and couples’ contraceptive use. Methods This egocentric network study was conducted among married/partnered men (n = 178) in rural Madagascar. Study participants listed who they relied on for FP information and advice, including health providers and social ties. They provided ties’ gender, age, relationship, and perceived support of contraceptive use. The primary outcome was couples’ contraceptive use, and explanatory variables included FP networks and their composition (no FP network, social-only network, provider-only network, and mixed network of social and provider ties). Analyses used generalized linear models specifying a Poisson distribution, with covariate adjustment and cluster robust standard errors. Results Men who had FP networks were 1.9 times more likely to use modern contraception as a couple compared to men with no FP network (95% confidence interval [CI] 1.64–2.52; p ≤ 0.001). Compared to men with no FP network, men were more likely to use modern contraception if they had a social-only network, relative risk (RR) = 2.10 (95% CI, 1.65–2.68; p ≤ 0.001); a provider-only network, RR = 1.80 (95% CI, 1.54–2.11; p ≤ 0.001); or a mixed network, RR = 2.35 (95% CI, 1.97–2.80; p ≤ 0.001). Conclusions Whether men have a FP network, be it provider or social ties, distinguishes if couples are using contraception. Interventions should focus on reaching men not only through providers but also through their social ties to foster communication and support for contraceptive use.
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Affiliation(s)
- Alison B Comfort
- University of California San Francisco, 550 16th Street, San Francisco, CA, 94158, USA. .,Opportunity Solutions International, San Francisco, CA, USA.
| | - Cynthia C Harper
- University of California San Francisco, 550 16th Street, San Francisco, CA, 94158, USA
| | - Alexander C Tsai
- Massachusetts General Hospital, Harvard Medical School, 125 Nashua Street, Suite 722, Boston, MA, 02114, USA
| | - Jessica M Perkins
- Peabody College of Education and Human Development, Vanderbilt University, PMB 90, 230 Appleton Place, Nashville, TN, 37203-5721, USA
| | - James Moody
- Duke University, 268 Soc/Psych Building, Durham, NC, 27708-0088, USA
| | - Justin Ranjalahy Rasolofomana
- Institut National de Santé Publique et Communautaire, Ex-Ecole de Médecine de Befelatanana, BP 176, Antananarivo, Madagascar
| | - Cora Alperin
- University of Chicago, 5438 S Woodlawn Avenue, Chicago, IL, 60615, USA
| | - Margaret Schultz
- Institute for Global Health Sciences, University of California San Francisco, 550 16th Street, Third Floor, San Francisco, CA, 94158, USA
| | | | - Ravo Heriniaina
- Opportunity Solutions International, Lot III G17, Ambalavao, Madagascar
| | - Paul J Krezanoski
- Opportunity Solutions International, San Francisco, CA, USA.,University of California San Francisco, Zuckerberg San Francisco General Hospital, 1001 Potrero Ave, San Francisco, CA, 94110, USA
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Biggs MA, Tome L, Mays A, Kaller S, Harper CC, Freedman L. The Fine Line Between Informing and Coercing: Community Health Center Clinicians' Approaches to Counseling Young People About IUDs. Perspect Sex Reprod Health 2020; 52:245-252. [PMID: 33289277 DOI: 10.1363/psrh.12161] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 08/10/2020] [Accepted: 08/24/2020] [Indexed: 06/12/2023]
Abstract
CONTEXT While community health centers (CHCs) are meeting increased demand for contraceptives, little is known about contraceptive counseling in these settings. Understanding how clinicians counsel about IUDs in CHCs, including whether they address or disregard young people's preferences and concerns during counseling, could improve contraceptive care. METHODS As part of a training program, 20 clinicians from 11 San Francisco Bay Area CHC sites who counsel young people about contraception were interviewed by telephone in 2015 regarding their IUD counseling approaches. An iterative grounded theory approach was used to analyze interview transcripts and identify salient themes related to clinicians' contraceptive counseling, IUD removal practices and efforts to address patient concerns regarding side effects. RESULTS Most clinicians offered comprehensive contraceptive counseling and method choice. While several clinicians viewed counseling as an opportunity to empower their patients to make contraceptive decisions without pressure, they also described a tension between guiding young people toward higher-efficacy methods and respecting patients' choices. Many clinicians engaged in what could be considered coercive practices by trying to dissuade patients from removals within a year of placement and offering to treat or downplay side effects. CONCLUSIONS Providers try to promote their young patients' autonomous decision making, but their support for high-efficacy methods can result in coercive practices. More training is needed to ensure that providers employ patient-centered counseling approaches, including honoring patient requests for removals.
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Affiliation(s)
- M Antonia Biggs
- Advancing New Standards in Reproductive Health, Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco
| | - Lucia Tome
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Aisha Mays
- Department of Family and Community Medicine, University of California, San Francisco
| | - Shelly Kaller
- Advancing New Standards in Reproductive Health, Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco
| | - Cynthia C Harper
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, School of Medicine, University of California, San Francisco
| | - Lori Freedman
- Advancing New Standards in Reproductive Health, Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco
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Harper CC, Comfort AB, Blum M, Rocca CH, McCulloch CE, Rao L, Shah N, Oquendo Del Toro H, Goodman S. Implementation science: Scaling a training intervention to include IUDs and implants in contraceptive services in primary care. Prev Med 2020; 141:106290. [PMID: 33096126 PMCID: PMC8032203 DOI: 10.1016/j.ypmed.2020.106290] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [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: 04/09/2020] [Revised: 10/10/2020] [Accepted: 10/13/2020] [Indexed: 10/23/2022]
Abstract
Building capacity for contraceptive services in primary care settings, including for intrauterine devices (IUDs) and implants, can help to broaden contraceptive access across the US. Following a randomized trial in family planning clinics, we brought a provider training intervention to other clinical settings including primary care in all regions. This implementation science study evaluates a national scale-up of a contraceptive training intervention to varied practice settings from 2013 to 2019 among 3216 clinic staff serving an estimated 1.6 million annual contraceptive patients. We measured providers' knowledge and clinical practice changes regarding IUDs and implants using survey data. We estimated the overall intervention effect, and its relative effectiveness in primary care settings, with generalized estimating equations for clustered data. Patient-centered counseling improved, along with comfort with method provision and removal. Provider knowledge increased (p < 0.001), as did evidence-based counseling for IUDs (aOR 3.3 95% CI 2.8-3.9) and implants (aOR 3.5, 95% CI 3.0-4.1), and clinician competency in copper and levonorgestrel IUDs (aORs 1.8-2.6 95% CIs 1.5-3.2) and implants (aOR 2.4 95% CI 2.0-2.9). While proficiency was lower initially in primary care, gains were significant and at times greater than in Planned Parenthood health clinics. This intervention was effectively scaled, including in primary care settings with limited prior experience with these methods. Recent changes to Title X family planning funding rules exclude several large family planning providers, shifting greater responsibility to primary care and other settings. Scaling effective contraceptive interventions is one way to ensure capacity to offer patients full contraceptive services.
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Affiliation(s)
- Cynthia C Harper
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco School of Medicine, United States of America.
| | - Alison B Comfort
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco School of Medicine, United States of America
| | - Maya Blum
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco School of Medicine, United States of America
| | - Corinne H Rocca
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco School of Medicine, United States of America
| | - Charles E McCulloch
- Department of Epidemiology and Biostatistics, University of California, San Francisco School of Medicine, United States of America
| | - Lavanya Rao
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco School of Medicine, United States of America
| | - Nishant Shah
- Consultant, Bixby Center for Global Reproductive Health, University of California, San Francisco, School of Medicine, United States of America
| | - Helen Oquendo Del Toro
- Department of Obstetrics and Gynecology, University of New Mexico School of Medicine, United States of America
| | - Suzan Goodman
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco School of Medicine, United States of America; Department of Family and Community Medicine, University of California, San Francisco School of Medicine, United States of America
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Barbieri JS, Mitra N, Margolis DJ, Harper CC, Mostaghimi A, Abuabara K. Influence of Contraception Class on Incidence and Severity of Acne Vulgaris. Obstet Gynecol 2020; 135:1306-1312. [PMID: 32459422 DOI: 10.1097/aog.0000000000003880] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [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
OBJECTIVE To evaluate the association of different contraceptive methods on the incidence and severity of acne. METHODS Using a de-identified commercial claims database, we performed a retrospective cohort study evaluating the incidence of clinical encounters for acne in the first year after initiation of contraception among female patients aged 12-40 years who were new contraceptive users. To evaluate the association of contraception class with acne severity, a subgroup analysis was performed among a cohort of patients with a history of acne examining the incidence of treatment escalation from topical acne medications to an oral tetracycline-class antibiotic in the year after initiation of contraception. RESULTS Among new contraceptive users with no history of acne (N=336,738), compared with combined oral contraceptives (OCs), the copper intrauterine device (IUD) (hazard ratio [HR] 1.14; 95% CI 1.01-1.29) and levonorgestrel IUDs (HR 1.09; 95% CI 1.03-1.16) were associated with increased risk of clinical encounters with acne. Among those with a history of acne (n=21,178), compared with combined OCs, the copper IUD (HR 1.44; 95% CI 1.00-2.06) and levonorgestrel IUDs (HR 1.34; 95% CI 1.10-1.64) were associated with increased risk of treatment escalation from topical acne medications to an oral tetracycline class antibiotic. CONCLUSION Combined OCs appear to be associated with a modest (or small) protective effect with respect to incident acne and treatment escalation compared with other contraceptive methods. However, absolute differences between contraceptive methods were small.
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Affiliation(s)
- John S Barbieri
- Departments of Dermatology and Biostatistics, Epidemiology & Informatics, University of Pennsylvania, Philadelphia, Pennsylvania; the Department of Obstetrics, Gynecology & Reproductive Sciences, Bixby Center for Global Reproductive Health, University of California, San Francisco, San Francisco, California; the Department of Dermatology, Brigham and Women's Hospital, Boston, Massachusetts; and the Department of Dermatology, University of California San Francisco, San Francisco, California
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Diamond-Smith N, Plaza N, Puri M, Dahal M, Weiser SD, Harper CC. Perceived Conflicting Desires to Delay the First Birth: A Household-Level Exploration in Nepal. Int Perspect Sex Reprod Health 2020; 46:125-133. [PMID: 32723708 DOI: 10.1363/46e9420] [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] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
CONTEXT It is accepted as the norm that couples in South Asia begin childbearing immediately after marriage and that, even if they would like to delay, they are pressured to have children by household members. Little research, however, has explored the desire to delay childbearing among newly married couples and their household members in Nepal-a setting with changing marriage formation patterns, increasing women's education and falling fertility. METHODS To explore the dynamics of current childbearing desires, in-depth interviews of 20 intact triads of newly married women, their husbands and their mothers-in-law were conducted in one district of Nepal in February-March 2017. Using thematic analysis, interviews were read and coded separately by type (wives, husbands, mothers-in-law), and then the triads were read together and coded to determine household-level patterns and themes. RESULTS Most newly married women and men want to delay their first birth, but have not communicated with each other about this. Even though couples are often in agreement about delaying, they feel pressured by in-laws and society to bear children early. Contrary to expectations, some mothers-in-law support delaying childbearing to allow their daughter-in-law to mature, continue her education or earn wages; however, they too perceive societal pressure. Male migration for work also contributes to early childbearing pressure. CONCLUSIONS Helping couples to sort through conflicting fertility norms and desires may be important to delay childbearing when desired. Programs should engage all household members, and work to increase couples' and household communication to address misperceptions about fertility desires.
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Affiliation(s)
- Nadia Diamond-Smith
- Assistant Professor, Department of Epidemiology and Biostatistics and Institute for Global Health Sciences, University of California, San Francisco, USA,
| | - Noemi Plaza
- Medical Student, Department of Medicine, University of California, San Francisco, USA
| | - Mahesh Puri
- Director of Research, Center for Research on Environment, Health and Population Activities, Kathmandu, Nepal
| | - Minakshi Dahal
- Program Manager, Center for Research on Environment, Health and Population Activities, Kathmandu, Nepal
| | - Sheri D Weiser
- Associate Professor, Department of Medicine, University of California, San Francisco, USA
| | - Cynthia C Harper
- Professor, Department of Obstetrics and Gynecology, University of California, San Francisco, USA
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Gitome SW, Kwena ZA, Harper CC, Cohen CR, Bukusi EA. Educating men about vaginal microbicides: considerations from Kenya. Cult Health Sex 2020; 22:660-674. [PMID: 31241426 DOI: 10.1080/13691058.2019.1627583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 06/01/2019] [Indexed: 06/09/2023]
Abstract
Men desire to be involved in their partner's decision-making about vaginal microbicide use. This coincides with women's desire to inform male partners about their microbicide use. Educating men about microbicides may enhance acceptability and generate critical support for the female participants of microbicide trials. In this multiphase mixed-methods study, we adapted an educational intervention on vaginal microbicides and tested it among men (n = 45) to determine its effect on men's knowledge regarding HIV/STI, vaginal microbicides and microbicide trials. We also conducted focus group discussions (FGDs) with the female partners (K = 3, n = 43) of the study participants and community representatives (K = 2, n = 24) to obtain their views on male partner microbicide education. We analysed FGD data for key themes using content analysis. HIV and vaginal microbicide knowledge scores increased significantly among men after the educational intervention. Both women and men highly supported male partner microbicide education, in the context of existing gender relations, to increase men's understanding about microbicides, promote adherence and help women gain their partners' trust. Complex gender dynamics should be considered when designing male partner educational interventions to improve acceptability and the use of microbicides and other female-initiated HIV prevention methods.
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Affiliation(s)
- Serah W Gitome
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Zachary A Kwena
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Cynthia C Harper
- Department of Obstetrics, Gynecology & Reproductive Sciences, Bixby Center for Global Reproductive Health, San Francisco, CA, USA
| | - Craig R Cohen
- Department of Obstetrics, Gynecology & Reproductive Sciences, Bixby Center for Global Reproductive Health, San Francisco, CA, USA
| | - Elizabeth A Bukusi
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
- Department of Obstetrics, Gynecology & Reproductive Sciences, Bixby Center for Global Reproductive Health, San Francisco, CA, USA
- Departments of Global Health and Obstetrics and Gynecology, University of Washington, Seattle, WA, USA
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Kaller S, Mays A, Freedman L, Harper CC, Biggs MA. Exploring young women's reasons for adopting intrauterine or oral emergency contraception in the United States: a qualitative study. BMC Womens Health 2020; 20:15. [PMID: 31992295 PMCID: PMC6986082 DOI: 10.1186/s12905-020-0886-z] [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] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 01/16/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The recent focus on increasing access to long-acting reversible contraceptive methods has often overlooked the diverse reasons why women may choose less effective methods even when significant access barriers have been removed. While the copper intrauterine device (IUD) is considered an acceptable alternative to emergency contraception pills (ECPs), it is unclear to what extent low rates of provision and use are due to patient preferences versus structural access barriers. This study explores factors that influence patients' choice between ECPs and the copper IUD as EC, including prior experiences with contraception and attitudes toward EC methods, in settings where both options are available at no cost. METHODS We telephone-interviewed 17 patients seeking EC from three San Francisco Bay Area youth-serving clinics that offered the IUD as EC and ECPs as standard practice, regarding their experiences choosing an EC method. We thematically coded all interview transcripts, then summarized the themes related to reasons for choosing ECPs or the IUD as EC. RESULTS Ten participants left their EC visit with ECPs and seven with the IUD as EC option. Women chose ECPs because they were familiar and easily accessible. Reasons for not adopting the copper IUD included having had prior negative experiences with the IUD, concerns about its side effects and the placement procedure, and lack of awareness about the copper IUD. Women who chose the IUD as EC did so primarily because of its long-term efficacy, invisibility, lack of hormones, longer window of post-coital utility, and a desire to not rely on ECPs. Women who chose the IUD as EC had not had prior negative experiences with the IUD, had already been interested in the IUD, and were ready and able to have it placed that day. CONCLUSIONS This study highlights that women have varied and well-considered reasons for choosing each EC method. Both ECPs and the copper IUD are important and acceptable EC options, each with their own features offering benefits to patients. Efforts to destigmatize repeated use of ECPs and validate women's choice of either EC method are needed to support women in their EC method decision-making.
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Affiliation(s)
- Shelly Kaller
- Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, 1330 Broadway, Suite 1100, Oakland, CA 94612 USA
| | - Aisha Mays
- Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, 1330 Broadway, Suite 1100, Oakland, CA 94612 USA
| | - Lori Freedman
- Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, 1330 Broadway, Suite 1100, Oakland, CA 94612 USA
| | - Cynthia C. Harper
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, 3333 California St, Suite 335, San Francisco, CA 94143 USA
| | - M. Antonia Biggs
- Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, 1330 Broadway, Suite 1100, Oakland, CA 94612 USA
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Drew LB, Mittal M, Thoma ME, Harper CC, Steinberg JR. Intimate Partner Violence and Effectiveness Level of Contraceptive Selection Post-Abortion. J Womens Health (Larchmt) 2019; 29:1142-1149. [PMID: 31721639 DOI: 10.1089/jwh.2018.7612] [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] [Indexed: 11/12/2022] Open
Abstract
Background: We examined whether experiencing more types of lifetime intimate partner violence (IPV) was independently associated with the effectiveness level of the contraceptive method women chose following an abortion. Materials and Methods: Using data on 245 women who were attending an urban hospital abortion clinic, we assessed whether women had ever experienced emotional, physical, or sexual IPV. Effectiveness of women's post-abortion contraceptive method selection was categorized into high (intrauterine device [IUD] and implant), moderate (pill, patch, ring, and shot), and low (condoms, emergency contraception, and none) effectiveness. Using multinomial logistic regression, we examined the relationship between number of types of IPV experienced and post-abortion contraceptive method effectiveness, adjusting for sociodemographics, prior abortion, having children, abortion trimester, importance of avoiding pregnancy in the next year, pre-abortion psychological distress, and effectiveness level of the contraceptive method women were planning to use before contraceptive counseling. Results: Twenty-seven percent (27%) of women experienced two or three types of IPV, 35% experienced one IPV type, and 38% experienced no IPV. Compared to women with no histories of IPV, women who experienced two or more types of IPV during their lifetimes were more likely to choose contraceptive methods with moderate effectiveness (adjusted odds ratio [AOR] = 5.23, 95% confidence interval [CI]: 1.13-24.23, p = 0.035) and high effectiveness (AOR = 5.01, 95% CI: 1.12-22.39, p = 0.035) than those with low effectiveness. Conclusion: Women who experienced two or more types of lifetime IPV selected more effective contraceptive methods post-abortion. Access to contraceptives that are not partner dependent, including long-acting reversible contraceptives (LARC), may be particularly important for women who have experienced multiple types of IPV.
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Affiliation(s)
- Laura B Drew
- Department of Family Science, School of Public Health, University of Maryland College Park, College Park, Maryland, USA
| | - Mona Mittal
- Department of Family Science, School of Public Health, University of Maryland College Park, College Park, Maryland, USA
| | - Marie E Thoma
- Department of Family Science, School of Public Health, University of Maryland College Park, College Park, Maryland, USA
| | - Cynthia C Harper
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco, San Francisco, California, USA
| | - Julia R Steinberg
- Department of Family Science, School of Public Health, University of Maryland College Park, College Park, Maryland, USA
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Comfort AB, Juras RC, Bradley SEK, Ranjalahy Rasolofomanana J, Noeliarivelo Ranjalahy A, Harper CC. Do home pregnancy tests bring women to community health workers for antenatal care counselling? A randomized controlled trial in Madagascar. Health Policy Plan 2019; 34:566-573. [DOI: 10.1093/heapol/czz080] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/22/2019] [Indexed: 11/14/2022] Open
Abstract
Abstract
Task-shifting the provision of pregnancy tests to community health workers (CHWs) in low-resource settings has the potential to reach significantly more underserved women at risk of pregnancy with essential reproductive health services. This study assessed whether an intervention to supply CHWs with home pregnancy tests brought more clients for antenatal care (ANC) counselling. We implemented a randomized controlled trial among CHWs providing reproductive health services to women in Eastern Madagascar. We used ordinary least squares regressions to estimate the effect of the intervention, with district- and month-fixed effects and CHW baseline characteristics as control variables. Our outcomes of interest included whether the intervention increased: (1) the number of women at risk of pregnancy who sought services from CHWs; (2) the number of these women who knew they were pregnant by the end of visit; and (3) the number of these women who received ANC counselling during visit. We found that providing pregnancy tests to CHWs to distribute to their clients for free significantly increased the number of women at risk of pregnancy who sought services from CHWs. At follow-up, treatment-group CHWs provided services to 6.3 clients compared with 4.2 clients among control-group CHWs, which represents a 50% relative increase from the control-group mean. A significantly higher number of these clients knew they were pregnant by the end of the visit, with a mean of 0.95 in treatment compared with 0.10 in control (Coeff. 0.86; 95% CI 0.59–1.13). A significantly higher number of these clients received antenatal counselling at the visit (Coeff. 0.4; 95% CI 0.14–0.64). Introducing free home pregnancy tests as part of community-based health services can improve pregnancy care by attracting more clients at risk of pregnancy to services at the community level, enabling more women to confirm they are pregnant and receive antenatal counselling.
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Affiliation(s)
- Alison B Comfort
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, Bixby Center for Global Reproductive Health, 3333 California Street, San Francisco, CA, USA
| | - Randall C Juras
- Abt Associates, Central Park West Suite 210, 5001 South Miami Boulevard, Durham, NC, USA
| | | | - Justin Ranjalahy Rasolofomanana
- Institut National de Santé Publique et Communautaire, Ex Ecole de médecine de Befelatanana, BP 176, Antananarivo, Madagascar
| | | | - Cynthia C Harper
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, Bixby Center for Global Reproductive Health, 3333 California Street, San Francisco, CA, USA
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Cabral MA, Schroeder R, Armstrong EM, El Ayadi AM, Gürel AL, Chang J, Harper CC. Pregnancy Intentions, Contraceptive Knowledge And Educational Aspirations Among Community College Students. Perspect Sex Reprod Health 2018; 50:181-188. [PMID: 30376215 DOI: 10.1363/psrh.12081] [Citation(s) in RCA: 12] [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] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 08/17/2018] [Accepted: 08/20/2018] [Indexed: 06/08/2023]
Abstract
CONTEXT Community college students, representing more than one-third of U.S. undergraduates, are a diverse population of young people motivated to seek higher education who are at elevated risk of unintended pregnancy. However, it is unknown how well prepared they are to prevent pregnancy and what they think about it in terms of their educational aspirations. METHODS In-depth interviews were conducted with 57 students aged 18-25, inclusive of all genders, in three community colleges in California in 2015. Content analysis was used to code data and identify themes. RESULTS All participants reported strong desires to prevent pregnancy in the next year and perceived their pregnancy risk as low, but many reported unprotected sex with opposite-sex partners. Participants had specific timelines for completing their degrees and believed pregnancy would make that far more challenging, but would not ultimately prevent them from achieving their goals. Female students expressed concern about the risks of exacerbated poverty, housing instability and unachieved career goals. Participants had little knowledge of their pregnancy risks and of the health benefits, side effects or effectiveness of contraceptives. They held negative beliefs about hormonal contraception (including emergency contraception, IUDs and the implant), fearing long-lasting effects and infertility. Gay or bisexual students shared concerns about contraceptives, although several were using methods for noncontraceptive reasons. CONCLUSION Many community college students not desiring pregnancy have limited awareness of pregnancy risk and prevention.
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Affiliation(s)
- Marta A Cabral
- Research analyst, Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, School of Medicine, University of California, San Francisco
| | - Rosalyn Schroeder
- Research, evaluation and data manager, Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, School of Medicine, University of California, San Francisco
| | | | - Alison M El Ayadi
- Assistant professor, Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, School of Medicine, University of California, San Francisco
| | - Aleka L Gürel
- Research analyst, Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, School of Medicine, University of California, San Francisco
| | - Janet Chang
- Director, Student Health Services, San Jose City College, San Jose, CA
| | - Cynthia C Harper
- Professor, Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, School of Medicine, University of California, San Francisco
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Steinberg JR, Adler NE, Thompson KM, Westhoff C, Harper CC. Current and past depressive symptoms and contraceptive effectiveness level method selected among women seeking reproductive health services. Soc Sci Med 2018; 214:20-25. [PMID: 30138841 DOI: 10.1016/j.socscimed.2018.08.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [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: 11/17/2017] [Revised: 08/02/2018] [Accepted: 08/12/2018] [Indexed: 12/24/2022]
Abstract
RATIONALE More thoroughly understanding the association between elevated depressive symptoms and effectiveness level of contraceptive method selected at a reproductive health visit could help women prevent unintended pregnancy. OBJECTIVE This study examined how the association between both current and past depressive symptoms and effectiveness level of contraceptive method selected at a clinic visit varies by type of reproductive health visit. METHODS Current and past depressive symptoms and contraceptive method selected were assessed among 1215 women aged 18-25 years seeking general reproductive health or abortion services at 40 community clinics throughout the United States. Using standard categories of effectiveness based on pregnancy rates during typical use, women's contraceptive method selected was coded as a low (e.g., no method, withdrawal, condoms), moderately (pill, patch, ring, or shot), or highly effective method (IUD, sterilization, implant). Depression status was divided into four categories: 1) no elevated depressive symptoms ever, 2) current elevated depressive symptoms only, 3) past elevated depressive symptoms only, and 4) past and current elevated depressive symptoms. Visit type, general reproductive health versus abortion care, was a moderator. The interaction effect between depressive symptoms and visit type on contraceptive method effectiveness level chosen was estimated with multinomial logistic regression analyses. RESULTS In general reproductive health visits, having both elevated current and past depressive symptoms increased women's likelihood of choosing low versus moderately effective methods (RRR = 5.63, 95% CI = 2.31 to 13.71, p < .0005). In contrast, among abortion patients, only current elevated depressive symptoms were associated with choosing high versus moderate effectiveness methods (RRR = 1.74, 95% CI = 1.06 to 2.86, p = .029). CONCLUSION Results suggest that considering both women's current and past elevated depressive symptoms and the type of reproductive health visit may assist providers in helping women prevent unintended pregnancy.
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Affiliation(s)
- Julia R Steinberg
- Department of Family Science, University of Maryland, College Park, United States.
| | - Nancy E Adler
- Department of Psychiatry, University of California, San Francisco, United States
| | - Kirsten M Thompson
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, United States
| | | | - Cynthia C Harper
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, United States
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Puri MC, Harper CC, Maharjan D, Blum M, Rocca CH. Pharmacy access to medical abortion from trained providers and post-abortion contraception in Nepal. Int J Gynaecol Obstet 2018; 143:211-216. [PMID: 29992555 DOI: 10.1002/ijgo.12595] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [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: 02/06/2018] [Revised: 05/16/2018] [Accepted: 07/09/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To examine whether auxiliary nurse-midwife provision of medical abortion in pharmacies was associated with reduced post-abortion contraceptive use in Nepal. METHODS The present prospective observational study compared contraceptive use among women aged 16-45 years and up to 63 days of pregnancy, who presented at one of six privately-owned pharmacies or six public health facilities in the Chitwan and Jhapa districts of Nepal for medical abortion between October 16, 2014, and September 1, 2015. Participants obtained medical abortions per Nepali protocol and completed a follow-up visit and interview at 14-21 days. Effective contraceptive use was compared between abortion care settings using multivariable mixed effects logistic regression. RESULTS Of 605 participants, 600 completed follow-up at 14-21 days; 474 (79.0%) were using a contraceptive method, most commonly pills (180 [30.0%]) and injectables (175 [29.2%]), followed by condoms (82 [13.7%]), long-acting reversible methods (33 [5.5%]), and sterilization (4 [0.7%]). Receipt of care from a private pharmacy was not associated with a difference in the use of hormonal or long-acting methods (adjusted odd ratio 0.89, 95% confidence interval 0.60-1.33). CONCLUSION Medical abortion provision from pharmacies by qualified providers can provide women with necessary induced-abortion care while not compromising longer-term pregnancy prevention.
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Affiliation(s)
- Mahesh C Puri
- Center for Research on Environment Health & Population Activities (CREHPA), Kusunti, Lalitpur, Kathmandu, Nepal
| | - Cynthia C Harper
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, School of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Dev Maharjan
- Center for Research on Environment Health & Population Activities (CREHPA), Kusunti, Lalitpur, Kathmandu, Nepal
| | - Maya Blum
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, School of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Corinne H Rocca
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, School of Medicine, University of California, San Francisco, San Francisco, CA, USA.,Advancing New Standards in Reproductive Health (ANSIRH), Department of Obstetrics, Gynecology and Reproductive Sciences, School of Medicine, University of California, San Francisco, Oakland, CA, USA
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Thompson KM, Rocca CH, Stern L, Morfesis J, Goodman S, Steinauer J, Harper CC. Training contraceptive providers to offer intrauterine devices and implants in contraceptive care: a cluster randomized trial. Am J Obstet Gynecol 2018; 218:597.e1-597.e7. [PMID: 29577915 DOI: 10.1016/j.ajog.2018.03.016] [Citation(s) in RCA: 23] [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: 12/13/2017] [Revised: 03/06/2018] [Accepted: 03/16/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND US unintended pregnancy rates remain high, and contraceptive providers are not universally trained to offer intrauterine devices and implants to women who wish to use these methods. OBJECTIVE We sought to measure the impact of a provider training intervention on integration of intrauterine devices and implants into contraceptive care. STUDY DESIGN We measured the impact of a continuing medical education-accredited provider training intervention on provider attitudes, knowledge, and practices in a cluster randomized trial in 40 US health centers from 2011 through 2013. Twenty clinics were randomly assigned to the intervention arm; 20 offered routine care. Clinic staff participated in baseline and 1-year surveys assessing intrauterine device and implant knowledge, attitudes, and practices. We used a difference-in-differences approach to compare changes that occurred in the intervention sites to changes in the control sites 1 year later. Prespecified outcome measures included: knowledge of patient eligibility for intrauterine devices and implants; attitudes about method safety; and counseling practices. We used multivariable regression with generalized estimating equations to account for clustering by clinic to examine intervention effects on provider outcomes 1 year later. RESULTS Overall, we surveyed 576 clinic staff (314 intervention, 262 control) at baseline and/or 1-year follow-up. The change in proportion of providers who believed that the intrauterine device was safe was greater in intervention (60% at baseline to 76% at follow-up) than control sites (66% at both times) (adjusted odds ratio, 2.48; 95% confidence interval, 1.13-5.4). Likewise, for the implant, the proportion increased from 57-77% in intervention, compared to 61-65% in control sites (adjusted odds ratio, 2.57; 95% confidence interval, 1.44-4.59). The proportion of providers who believed they were experienced to counsel on intrauterine devices also increased in intervention (53-67%) and remained the same in control sites (60%) (adjusted odds ratio, 1.89; 95% confidence interval, 1.04-3.44), and for the implant increased more in intervention (41-62%) compared to control sites (48-50%) (adjusted odds ratio, 2.30; 95% confidence interval, 1.28-4.12). Knowledge scores of patient eligibility for intrauterine devices increased at intervention sites (from 0.77-0.86) 6% more over time compared to control sites (from 0.78-0.80) (adjusted coefficient, 0.058; 95% confidence interval, 0.003-0.113). Knowledge scores of eligibility for intrauterine device and implant use with common medical conditions increased 15% more in intervention (0.65-0.79) compared to control sites (0.67-0.66) (adjusted coefficient, 0.15; 95% confidence interval, 0.09-0.21). Routine discussion of intrauterine devices and implants by providers in intervention sites increased significantly, 71-87%, compared to in control sites, 76-82% (adjusted odds ratio, 1.97; 95% confidence interval, 1.02-3.80). CONCLUSION Professional guidelines encourage intrauterine device and implant competency for all contraceptive care providers. Integrating these methods into routine care is important for access. This replicable training intervention translating evidence into care had a sustained impact on provider attitudes, knowledge, and counseling practices, demonstrating significant changes in clinical care a full year after the training intervention.
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Goodman SR, El Ayadi AM, Rocca CH, Kohn JE, Benedict CE, Dieseldorff JR, Harper CC. The intrauterine device as emergency contraception: how much do young women know? Contraception 2018; 98:S0010-7824(18)30145-8. [PMID: 29679591 PMCID: PMC6546552 DOI: 10.1016/j.contraception.2018.04.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 04/10/2018] [Accepted: 04/11/2018] [Indexed: 12/30/2022]
Abstract
BACKGROUND Unprotected intercourse is common, especially among teens and young women. Access to intrauterine device (IUD) as emergency contraception (EC) can help interested patients more effectively prevent unintended pregnancy and can also offer ongoing contraception. This study evaluated young women's awareness of IUD as EC and interest in case of need. STUDY DESIGN We conducted a secondary analysis of data from young women aged 18-25 years, not desiring pregnancy within 12 months, and receiving contraceptive counseling within a cluster-randomized trial in 40 US Planned Parenthood health centers in 2011-2013 (n=1500). Heath centers were randomized to receive enhanced training on contraceptive counseling and IUD placement, or to provide standard care. The intervention did not focus specifically on IUD as EC. We assessed awareness of IUD as EC, desire to learn more about EC and most trusted source of information of EC among women in both intervention and control groups completing baseline and 3- or 6-month follow-up questionnaires (n=1138). RESULTS At follow-up, very few young women overall (7.5%) visiting health centers had heard of IUD as EC. However, if they needed EC, most (68%) reported that they would want to learn about IUDs in addition to EC pills, especially those who would be very unhappy to become pregnant (adjusted odds ratio [aOR], 1.3; 95% confidence interval, 1.0-1.6, p<.05). Most (91%) reported a doctor or nurse as their most trusted source of EC information, over Internet (6%) or friends (2%), highlighting providers' essential role. CONCLUSION Most young women at risk of unintended pregnancy are not aware of IUD as EC and look to their providers for trusted information. Contraceptive education should explicitly address IUD as EC. IMPLICATIONS Few young women know that the IUD can be used for EC or about its effectiveness. However, if they needed EC, most reported that they would want to learn about IUDs in addition to EC pills, especially those very unhappy to become pregnant. Contraceptive education should explicitly address IUD as EC.
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Affiliation(s)
- Suzan R Goodman
- UCSF Bixby Center for Global Reproductive Health, 3333 California Street, UCSF Box 0744, San Francisco, CA 94143-0744, USA.
| | - Alison M El Ayadi
- UCSF Bixby Center for Global Reproductive Health, 3333 California Street, UCSF Box 0744, San Francisco, CA 94143-0744, USA
| | - Corinne H Rocca
- UCSF Bixby Center for Global Reproductive Health, 3333 California Street, UCSF Box 0744, San Francisco, CA 94143-0744, USA
| | - Julia E Kohn
- Planned Parenthood Federation of America, 123 William Street, New York, NY 10038, USA
| | - Courtney E Benedict
- Planned Parenthood Federation of America, 123 William Street, New York, NY 10038, USA
| | | | - Cynthia C Harper
- UCSF Bixby Center for Global Reproductive Health, 3333 California Street, UCSF Box 0744, San Francisco, CA 94143-0744, USA
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Keesara S, Juma PA, Harper CC, Newmann SJ. Barriers to postpartum contraception: differences among women based on parity and future fertility desires. Cult Health Sex 2018; 20:247-261. [PMID: 28705100 DOI: 10.1080/13691058.2017.1340669] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
Timely use of contraception in the postpartum year is critical for pregnancy spacing, which protects a mother's health and improves her ability to care for children. This qualitative study explored contraceptive decision-making among postpartum women in Nairobi, Kenya, with a focus on accounts of how women overcame barriers to postpartum contraceptive use. Focus groups (n = 61) and in-depth interviews (n = 30) explored experiences, barriers and actual use of postpartum contraception. Data were analysed using framework analysis, a method that organises qualitative data into themes and then interprets the data by mapping participant characteristics to these themes. Contraceptive use among women who desired future fertility was hindered by fear of side-effects and concern for partner disapproval. However, women who were satisfied with their family size more easily overcame these barriers. Tailoring postpartum contraceptive counselling to both assuage the concerns of women who desire future fertility and address the long-term contraceptive needs of mothers who desire to stop child-bearing could play a role in reducing the unmet need for contraception. .
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Affiliation(s)
- Sirina Keesara
- a Department of Obstetrics and Gynecology , University of Chicago Medical Center , Chicago , USA
| | - Pamela A Juma
- b Population Dynamic & Reproductive Health , African Population and Health Research Center , Nairobi , Kenya
| | - Cynthia C Harper
- c Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences , University of California , San Francisco , USA
| | - Sara J Newmann
- c Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences , University of California , San Francisco , USA
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Rocca CH, Puri M, Shrestha P, Blum M, Maharjan D, Grossman D, Regmi K, Darney PD, Harper CC. Effectiveness and safety of early medication abortion provided in pharmacies by auxiliary nurse-midwives: A non-inferiority study in Nepal. PLoS One 2018; 13:e0191174. [PMID: 29351313 PMCID: PMC5774715 DOI: 10.1371/journal.pone.0191174] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Accepted: 12/27/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Expanding access to medication abortion through pharmacies is a promising avenue to reach women with safe and convenient care, yet no pharmacy provision interventions have been evaluated. This observational non-inferiority study investigated the effectiveness and safety of mifepristone-misoprostol medication abortion provided at pharmacies, compared to government-certified public health facilities, by trained auxiliary nurse-midwives in Nepal. METHODS Auxiliary nurse-midwives were trained to provide medication abortion through twelve pharmacies and public facilities as part of a demonstration project in two districts. Eligible women were ≤63 days pregnant, aged 16-45, and had no medical contraindications. Between 2014-2015, participants (n = 605) obtained 200 mg mifepristone orally and 800 μg misoprostol sublingually or intravaginally 24 hours later, and followed-up 14-21 days later. The primary outcome was complete abortion without manual vacuum aspiration; the secondary outcome was complication requiring treatment. We assessed risk differences by facility type with multivariable logistic mixed-effects regression. RESULTS Over 99% of enrolled women completed follow-up (n = 600). Complete abortions occurred in 588 (98·0%) cases, with ten incomplete abortions and two continuing pregnancies. 293/297 (98·7%) pharmacy participants and 295/303 (97·4%) public facility participants had complete abortions, with an adjusted risk difference falling within the pre-specified 5 percentage-point non-inferiority margin (1·5% [-0·8%, 3·8%]). No serious adverse events occurred. Five (1.7%) pharmacy and two (0.7%) public facility participants experienced a complication warranting treatment (aRD, 0.8% [-1.0%-2.7%]). CONCLUSIONS Early mifepristone-misoprostol abortion was as effective and safe when provided by trained auxiliary nurse-midwives at pharmacies as at government-certified health facilities. Findings support policy expanding provision through registered pharmacies by trained auxiliary nurse-midwives to improve access to safe care.
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Affiliation(s)
- Corinne H. Rocca
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, School of Medicine, University of California San Francisco, San Francisco, CA, United States of America
- Advancing New Standards in Reproductive Health (ANSIRH), Department of Obstetrics, Gynecology and Reproductive Sciences, School of Medicine, University of California San Francisco, Oakland, CA, United States of America
- * E-mail:
| | - Mahesh Puri
- Center for Research on Environment Health & Population Activities (CREHPA), Kusunti, Lalitpur, Kathmandu, Nepal
| | - Prabhakar Shrestha
- Center for Research on Environment Health & Population Activities (CREHPA), Kusunti, Lalitpur, Kathmandu, Nepal
| | - Maya Blum
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, School of Medicine, University of California San Francisco, San Francisco, CA, United States of America
| | - Dev Maharjan
- Center for Research on Environment Health & Population Activities (CREHPA), Kusunti, Lalitpur, Kathmandu, Nepal
| | - Daniel Grossman
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, School of Medicine, University of California San Francisco, San Francisco, CA, United States of America
- Advancing New Standards in Reproductive Health (ANSIRH), Department of Obstetrics, Gynecology and Reproductive Sciences, School of Medicine, University of California San Francisco, Oakland, CA, United States of America
| | | | - Philip D. Darney
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, School of Medicine, University of California San Francisco, San Francisco, CA, United States of America
| | - Cynthia C. Harper
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, School of Medicine, University of California San Francisco, San Francisco, CA, United States of America
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Antonia Biggs M, Kaller S, Harper CC, Freedman L, Mays AR. "Birth Control can Easily Take a Back Seat": Challenges Providing IUDs in Community Health Care Settings. J Health Care Poor Underserved 2018; 29:228-244. [DOI: 10.1353/hpu.2018.0016] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Rocca CH, Goodman S, Grossman D, Cadwallader K, Thompson KMJ, Talmont E, Speidel JJ, Harper CC. Contraception after medication abortion in the United States: results from a cluster randomized trial. Am J Obstet Gynecol 2018; 218:107.e1-107.e8. [PMID: 28986072 DOI: 10.1016/j.ajog.2017.09.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Revised: 09/19/2017] [Accepted: 09/21/2017] [Indexed: 11/27/2022]
Abstract
BACKGROUND Understanding how contraceptive choices and access differ for women having medication abortions compared to aspiration procedures can help to identify priorities for improved patient-centered postabortion contraceptive care. OBJECTIVE The objective of this study was to investigate the differences in contraceptive counseling, method choices, and use between medication and aspiration abortion patients. STUDY DESIGN This subanalysis examines data from 643 abortion patients from 17 reproductive health centers in a cluster, randomized trial across the United States. We recruited participants aged 18-25 years who did not desire pregnancy and followed them for 1 year. We measured the effect of a full-staff contraceptive training and abortion type on contraceptive counseling, choice, and use with multivariable regression models, using generalized estimating equations for clustering. We used survival analysis with shared frailty to model actual intrauterine device and subdermal implant initiation over 1 year. RESULTS Overall, 26% of participants (n = 166) had a medication abortion and 74% (n = 477) had an aspiration abortion at the enrollment visit. Women obtaining medication abortions were as likely as those having aspiration abortions to receive counseling on intrauterine devices or the implant (55%) and on a short-acting hormonal method (79%). The proportions of women choosing to use these methods (29% intrauterine device or implant, 58% short-acting hormonal) were also similar by abortion type. The proportions of women who actually used short-acting hormonal methods (71% medication vs 57% aspiration) and condoms or no method (20% vs 22%) within 3 months were not significantly different by abortion type. However, intrauterine device initiation over a year was significantly lower after the medication than the aspiration abortion (11 per 100 person-years vs 20 per 100 person-years, adjusted hazard ratio, 0.50; 95% confidence interval, 0.28-0.89). Implant initiation rates were low and similar by abortion type (5 per 100 person-years vs 4 per 100 person-years, adjusted hazard ratio, 2.41; 95% confidence interval, 0.88-6.59). In contrast to women choosing short-acting methods, relatively few of those choosing a long-acting method at enrollment, 34% of medication abortion patients and 53% of aspiration abortion patients, had one placed within 3 months. Neither differences in health insurance nor pelvic examination preferences by abortion type accounted for lower intrauterine device use among medication abortion patients. CONCLUSION Despite similar contraceptive choices, fewer patients receiving medication abortion than aspiration abortion initiated intrauterine devices over 1 year of follow-up. Interventions to help patients receiving medication abortion to successfully return for intrauterine device placement are warranted. New protocols for same-day implant placement may also help patients receiving medication abortion and desiring a long-acting method to receive one.
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Affiliation(s)
- Corinne H Rocca
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology, and Reproductive Sciences, School of Medicine, University of California, San Francisco, San Francisco, CA; Advancing New Standards in Reproductive Health, Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology, and Reproductive Sciences, School of Medicine, University of California, San Francisco, Oakland, CA.
| | - Suzan Goodman
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology, and Reproductive Sciences, School of Medicine, University of California, San Francisco, San Francisco, CA
| | - Daniel Grossman
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology, and Reproductive Sciences, School of Medicine, University of California, San Francisco, San Francisco, CA; Advancing New Standards in Reproductive Health, Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology, and Reproductive Sciences, School of Medicine, University of California, San Francisco, Oakland, CA
| | - Kara Cadwallader
- Planned Parenthood of the Great Northwest and the Hawaiian Islands, Seattle, WA
| | - Kirsten M J Thompson
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology, and Reproductive Sciences, School of Medicine, University of California, San Francisco, San Francisco, CA
| | - Elizabeth Talmont
- Planned Parenthood of Northern, Central, and Southern New Jersey Inc, Morristown, NJ
| | - J Joseph Speidel
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology, and Reproductive Sciences, School of Medicine, University of California, San Francisco, San Francisco, CA
| | - Cynthia C Harper
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology, and Reproductive Sciences, School of Medicine, University of California, San Francisco, San Francisco, CA
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El Ayadi AM, Rocca CH, Kohn JE, Velazquez D, Blum M, Newmann SJ, Harper CC. The impact of an IUD and implant intervention on dual method use among young women: Results from a cluster randomized trial. Prev Med 2017; 94:1-6. [PMID: 27773708 PMCID: PMC6373723 DOI: 10.1016/j.ypmed.2016.10.015] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [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: 04/27/2016] [Revised: 10/13/2016] [Accepted: 10/18/2016] [Indexed: 11/18/2022]
Abstract
Long-acting reversible contraceptives (LARCs) are highly effective at preventing pregnancy but do not protect against sexually transmitted infection (STI). Recent efforts to improve access to intrauterine devices (IUDs) and implants have raised concerns about STI prevention and reduced condom use, particularly among teenagers and young women. We evaluated whether a provider-targeted intervention to increase LARC access negatively impacted dual method use and STI incidence among an at-risk patient population. We conducted a cluster randomized trial in 40 reproductive health centers across the United States from May 2011 to May 2013. After training providers at 20 intervention sites, we recruited 1500 sexually-active women aged 18-25years who did not desire pregnancy and followed them for one year. We assessed intervention effects on dual method use, condom use and STI incidence, modeling dual method use with generalized estimating equations and STI incidence with Cox proportional hazard regression models, accounting for clustering. We found no differences between intervention and control groups in dual method use (14.3% vs. 14.4%, aOR 1.03, 95% CI 0.74-1.44) or condom use (30% vs. 31%, aOR 1.03, 95% CI 0.79-1.35) at last sex at one year. STI incidence was 16.5 per 100 person-years and did not differ between intervention and control groups (aHR 1.20, 95% CI 0.88-1.64). A provider training intervention to increase LARC access neither compromised condom use nor increased STI incidence among young women. Dual method use was very low overall, highlighting the need to bolster STI prevention efforts among adolescents and young women.
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Affiliation(s)
- Alison M El Ayadi
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, United States.
| | - Corinne H Rocca
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, United States
| | - Julia E Kohn
- Planned Parenthood Federation of America, United States
| | | | - Maya Blum
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, United States
| | - Sara J Newmann
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, United States
| | - Cynthia C Harper
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, United States
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Rocca CH, Thompson KMJ, Goodman S, Westhoff CL, Harper CC. Funding policies and postabortion long-acting reversible contraception: results from a cluster randomized trial. Am J Obstet Gynecol 2016; 214:716.e1-8. [PMID: 26692178 DOI: 10.1016/j.ajog.2015.12.009] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Revised: 11/06/2015] [Accepted: 12/07/2015] [Indexed: 11/15/2022]
Abstract
BACKGROUND Almost one-half of women having an abortion in the United States have had a previous procedure, which highlights a failure to provide adequate preventive care. Provision of intrauterine devices and implants, which have high upfront costs, can be uniquely challenging in the abortion care setting. OBJECTIVE We conducted a study of a clinic-wide training intervention on long-acting reversible contraception and examined the effect of the intervention, insurance coverage, and funding policies on the use of long-acting contraceptives after an abortion. STUDY DESIGN This subanalysis of a cluster, randomized trial examines data from the 648 patients who had undergone an abortion who were recruited from 17 reproductive health centers across the United States. The trial followed participants 18-25 years old who did not desire pregnancy for a year. We measured the effect of the intervention, health insurance, and funding policies on contraceptive outcomes, which included intrauterine device and implant counseling and selection at the abortion visit, with the use of logistic regression with generalized estimating equations for clustering. We used survival analysis to model the actual initiation of these methods over 1 year. RESULTS Women who obtained abortion care at intervention sites were more likely to report intrauterine device and implant counseling (70% vs 41%; adjusted odds ratio, 3.83; 95% confidence interval, 2.37-6.19) and the selection of these methods (36% vs 21%; adjusted odds ratio, 2.11; 95% confidence interval, 1.39-3.21). However, the actual initiation of methods was similar between study arms (22/100 woman-years each; adjusted hazard ratio, 0.88; 95% confidence interval, 0.51-1.51). Health insurance and funding policies were important for the initiation of intrauterine devices and implants. Compared with uninsured women, those women with public health insurance had a far higher initiation rate (adjusted hazard ratio, 2.18; 95% confidence interval, 1.31-3.62). Women at sites that provide state Medicaid enrollees abortion coverage also had a higher initiation rate (adjusted hazard ratio, 1.73; 95% confidence interval, 1.04-2.88), as did those at sites with state mandates for private health insurance to cover contraception (adjusted hazard ratio, 1.80; 95% confidence interval, 1.06-3.07). Few of the women with private insurance used it to pay for the abortion (28%), but those who did initiated long-acting contraceptive methods at almost twice the rate as women who paid for it themselves or with donated funds (adjusted hazard ratio, 1.94; 95% confidence interval, 1.10-3.43). CONCLUSIONS The clinic-wide training increased long-acting reversible contraceptive counseling and selection but did not change initiation for abortion patients. Long-acting method use after abortion was associated strongly with funding. Restrictions on the coverage of abortion and contraceptives in abortion settings prevent the initiation of desired long-acting methods.
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Affiliation(s)
- Corinne H Rocca
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, School of Medicine, University of California, San Francisco, San Francisco, CA.
| | - Kirsten M J Thompson
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, School of Medicine, University of California, San Francisco, San Francisco, CA
| | - Suzan Goodman
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, School of Medicine, University of California, San Francisco, San Francisco, CA
| | - Carolyn L Westhoff
- Planned Parenthood Federation of America and the Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, NY
| | - Cynthia C Harper
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, School of Medicine, University of California, San Francisco, San Francisco, CA
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Thompson KMJ, Rocca CH, Kohn JE, Goodman S, Stern L, Blum M, Speidel JJ, Darney PD, Harper CC. Public Funding for Contraception, Provider Training, and Use of Highly Effective Contraceptives: A Cluster Randomized Trial. Am J Public Health 2016; 106:541-6. [PMID: 26794168 PMCID: PMC4816144 DOI: 10.2105/ajph.2015.303001] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/19/2015] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We determined whether public funding for contraception was associated with long-acting reversible contraceptive (LARC) use when providers received training on these methods. METHODS We evaluated the impact of a clinic training intervention and public funding on LARC use in a cluster randomized trial at 40 randomly assigned clinics across the United States (2011-2013). Twenty intervention clinics received a 4-hour training. Women aged 18 to 25 were enrolled and followed for 1 year (n = 1500: 802 intervention, 698 control). We estimated the effects of the intervention and funding sources on LARC initiation with Cox proportional hazards models with shared frailty. RESULTS Women at intervention sites had higher LARC initiation than those at control (22 vs 18 per 100 person-years; adjusted hazard ratio [AHR] = 1.43; 95% confidence interval [CI] = 1.04, 1.98). Participants receiving care at clinics with Medicaid family planning expansion programs had almost twice the initiation rate as those at clinics without (25 vs 13 per 100 person-years; AHR = 2.26; 95% CI = 1.59, 3.19). LARC initiation also increased among participants with public (AHR = 1.56; 95% CI = 1.09, 2.22) but not private health insurance. CONCLUSIONS Public funding and provider training substantially improve LARC access.
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Affiliation(s)
- Kirsten M J Thompson
- Kirsten M. J. Thompson, Corinne H. Rocca, Suzan Goodman, Maya Blum, J. Joseph Speidel, Philip D. Darney, and Cynthia C. Harper are with the Bixby Center for Global Reproductive Health, University of California, San Francisco. Julia E. Kohn and Lisa Stern are with Planned Parenthood Federation of America, New York, NY
| | - Corinne H Rocca
- Kirsten M. J. Thompson, Corinne H. Rocca, Suzan Goodman, Maya Blum, J. Joseph Speidel, Philip D. Darney, and Cynthia C. Harper are with the Bixby Center for Global Reproductive Health, University of California, San Francisco. Julia E. Kohn and Lisa Stern are with Planned Parenthood Federation of America, New York, NY
| | - Julia E Kohn
- Kirsten M. J. Thompson, Corinne H. Rocca, Suzan Goodman, Maya Blum, J. Joseph Speidel, Philip D. Darney, and Cynthia C. Harper are with the Bixby Center for Global Reproductive Health, University of California, San Francisco. Julia E. Kohn and Lisa Stern are with Planned Parenthood Federation of America, New York, NY
| | - Suzan Goodman
- Kirsten M. J. Thompson, Corinne H. Rocca, Suzan Goodman, Maya Blum, J. Joseph Speidel, Philip D. Darney, and Cynthia C. Harper are with the Bixby Center for Global Reproductive Health, University of California, San Francisco. Julia E. Kohn and Lisa Stern are with Planned Parenthood Federation of America, New York, NY
| | - Lisa Stern
- Kirsten M. J. Thompson, Corinne H. Rocca, Suzan Goodman, Maya Blum, J. Joseph Speidel, Philip D. Darney, and Cynthia C. Harper are with the Bixby Center for Global Reproductive Health, University of California, San Francisco. Julia E. Kohn and Lisa Stern are with Planned Parenthood Federation of America, New York, NY
| | - Maya Blum
- Kirsten M. J. Thompson, Corinne H. Rocca, Suzan Goodman, Maya Blum, J. Joseph Speidel, Philip D. Darney, and Cynthia C. Harper are with the Bixby Center for Global Reproductive Health, University of California, San Francisco. Julia E. Kohn and Lisa Stern are with Planned Parenthood Federation of America, New York, NY
| | - J Joseph Speidel
- Kirsten M. J. Thompson, Corinne H. Rocca, Suzan Goodman, Maya Blum, J. Joseph Speidel, Philip D. Darney, and Cynthia C. Harper are with the Bixby Center for Global Reproductive Health, University of California, San Francisco. Julia E. Kohn and Lisa Stern are with Planned Parenthood Federation of America, New York, NY
| | - Philip D Darney
- Kirsten M. J. Thompson, Corinne H. Rocca, Suzan Goodman, Maya Blum, J. Joseph Speidel, Philip D. Darney, and Cynthia C. Harper are with the Bixby Center for Global Reproductive Health, University of California, San Francisco. Julia E. Kohn and Lisa Stern are with Planned Parenthood Federation of America, New York, NY
| | - Cynthia C Harper
- Kirsten M. J. Thompson, Corinne H. Rocca, Suzan Goodman, Maya Blum, J. Joseph Speidel, Philip D. Darney, and Cynthia C. Harper are with the Bixby Center for Global Reproductive Health, University of California, San Francisco. Julia E. Kohn and Lisa Stern are with Planned Parenthood Federation of America, New York, NY
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Rafie S, Kelly S, Gray EK, Wong M, Gibbs S, Harper CC. Provider Opinions Regarding Expanding Access to Hormonal Contraception in Pharmacies. Womens Health Issues 2016; 26:153-60. [DOI: 10.1016/j.whi.2015.09.006] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Revised: 09/17/2015] [Accepted: 09/21/2015] [Indexed: 10/22/2022]
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Hsu A, Henderson JT, Harper CC, Sawaya GF. Obstetrician-Gynecologist Practices and Beliefs Regarding External Genitalia Inspection and Speculum Examinations in Healthy Older Asymptomatic Women. J Am Geriatr Soc 2016; 64:293-8. [PMID: 26805728 DOI: 10.1111/jgs.13954] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To understand obstetrician-gynecologist perceptions of the value of external genitalia inspection and speculum examinations in older and younger healthy women across the life span. DESIGN National survey from May 2010 to January 2011 asking obstetrician-gynecologists about the need for and importance of external inspection and speculum examination in four scenarios of asymptomatic healthy women aged 70, 55, 35, and 18 who present for routine health visits. Separate questions asked about the importance of various reasons for these examinations. SETTING Mail-in survey of a national sample of obstetrician-gynecologists. PARTICIPANTS Probability sample of obstetrician-gynecologists from the American Medical Association Physician Masterfile (N = 521). MEASUREMENTS Proportion of obstetrician-gynecologists who would perform external inspection and speculum examinations and consider these examinations to be very important. RESULTS The response rate was 62%. In a healthy 70-year-old woman, 98% of respondents would perform external inspection, and 86% would perform a speculum examination. Ninety percent would perform a speculum examination in a healthy 55-year-old woman after removal of her uterus, cervix, and ovaries. Respondents more often indicated that the external examination was very important in the 70-year-old (63%) than in younger women (46-53%). Reasons rated as very important included identifying cancers and benign lesions, reassuring women of their health, and adhering to standard of care. CONCLUSION Obstetrician-gynecologists would commonly perform external and speculum examinations in asymptomatic women and believe the external examination to be particularly important in older women for cancer detection. Clinicians should discuss limitations of screening pelvic examination guidelines and elicit health goals from older women to provide more person-centered gynecological care.
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Affiliation(s)
- Amy Hsu
- Division of Geriatrics, Veterans Affairs Medical Center, San Francisco, California
| | | | - Cynthia C Harper
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California at San Francisco, San Francisco, California
| | - George F Sawaya
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California at San Francisco, San Francisco, California
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Steinberg JR, Tschann JM, Furgerson D, Harper CC. Psychosocial factors and pre-abortion psychological health: The significance of stigma. Soc Sci Med 2015; 150:67-75. [PMID: 26735332 DOI: 10.1016/j.socscimed.2015.12.007] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [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: 06/25/2015] [Revised: 09/09/2015] [Accepted: 12/04/2015] [Indexed: 01/21/2023]
Abstract
RATIONALE Most research in mental health and abortion has examined factors associated with post-abortion psychological health. However, research that follows women from before to after their abortion consistently finds that depressive, anxiety, and stress symptoms are highest just before an abortion compared to any time afterwards. OBJECTIVE This finding suggests that studies investigating psychosocial factors related to pre-abortion mental health are warranted. METHODS The current study uses data from 353 women seeking abortions at three community reproductive health clinics to examine predictors of pre-abortion psychological health. Drawing from three perspectives in the abortion and mental health literature, common risks, stress and coping, and sociocultural context, we conducted multivariable analyses to examine the contribution of important factors on depressive, anxiety, and stress symptoms just before an abortion, including sociodemographics, abortion characteristics, childhood adversities, recent adversities with an intimate partner, relationship context, future pregnancy desires, and perceived abortion stigma. RESULTS Childhood and partner adversities, including reproductive coercion, were associated with negative mental health symptoms, as was perceived abortion stigma. Before perceived abortion stigma was entered into the model, 18.6%, 20.7%, and 16.8% of the variance in depressive, anxiety, and stress symptoms respectively, was explained. Perceived abortion stigma explained an additional 13.2%, 9.7%, and 10.7% of the variance in depressive, anxiety, and stress symptoms pre-abortion. CONCLUSION This study, one of the first to focus on pre-abortion mental health as an outcome, suggests that addressing stigma among women seeking abortions may significantly lower their psychological distress.
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Affiliation(s)
- Julia R Steinberg
- Department of Family Science, University of Maryland College Park, USA.
| | - Jeanne M Tschann
- Department of Psychiatry, University of California, San Francisco, USA
| | | | - Cynthia C Harper
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, USA
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Schneider A, Henderson JT, Harper CC, Hsu A, Saraiya M, Sawaya GF. Obstetrician-gynecologists' beliefs about performing less cervical cancer screening: the pendulum swings. Am J Obstet Gynecol 2015; 213:744-5. [PMID: 26184779 DOI: 10.1016/j.ajog.2015.07.003] [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: 06/30/2015] [Accepted: 07/07/2015] [Indexed: 10/23/2022]
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Keesara SR, Juma PA, Harper CC. Why do women choose private over public facilities for family planning services? A qualitative study of post-partum women in an informal urban settlement in Kenya. BMC Health Serv Res 2015; 15:335. [PMID: 26290181 PMCID: PMC4545906 DOI: 10.1186/s12913-015-0997-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Accepted: 08/11/2015] [Indexed: 11/10/2022] Open
Abstract
Background Nearly 40 % of women in developing countries seek contraceptives services from the private sector. However, the reasons that contraceptive clients choose private or public providers are not well studied. Methods We conducted six focus groups discussions and 51 in-depth interviews with postpartum women (n = 61) to explore decision-making about contraceptive use after delivery, including facility choice. Results When seeking contraceptive services, women in this study preferred private over public facilities due to convenience and timeliness of services. Women avoided public facilities due to long waits and disrespectful providers. Study participants reported, however, that they felt more confident about the technical medical quality in public facilities than in private, and believed that private providers prioritized profit over safe medical practice. Women reported that public facilities offered comprehensive counseling and chose these facilities when they needed contraceptive decision-support. Provision of comprehensive counseling and screening, including side effects counseling and management, determined perception of quality. Conclusion Women believed private providers offered the advantages of convenience, efficiency and privacy, though they did not consistently offer high-quality care. Quality-improvement of contraceptive care at private facilities could include technical standardization and accreditation. Development of support and training for side effect management may be an important intervention to improve perceived quality of care.
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Affiliation(s)
- Sirina R Keesara
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, USA.
| | - Pamela A Juma
- African Population Health Research Center, Nairobi, Kenya.
| | - Cynthia C Harper
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, USA.
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Harper CC, Rocca CH, Thompson KM, Morfesis J, Goodman S, Darney PD, Westhoff CL, Speidel JJ. Reductions in pregnancy rates in the USA with long-acting reversible contraception: a cluster randomised trial. Lancet 2015; 386:562-8. [PMID: 26091743 DOI: 10.1016/s0140-6736(14)62460-0] [Citation(s) in RCA: 136] [Impact Index Per Article: 15.1] [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: 11/26/2022]
Abstract
BACKGROUND Unintended pregnancy remains a serious public health challenge in the USA. We assessed the effects of an intervention to increase patients' access to long-acting reversible contraceptives (LARCs) on pregnancy rates. METHODS We did a cluster randomised trial in 40 reproductive health clinics across the USA in 2011-13. 20 clinics were randomly assigned to receive evidence-based training on providing counselling and insertion of intrauterine devices (IUDs) or progestin implants and 20 to provide standard care. Usual costs for contraception were maintained at all sites. We recruited women aged 18-25 years attending family planning or abortion care visits and not desiring pregnancy in the next 12 months. The primary outcome was selection of an IUD or implant at the clinic visit and secondary outcome was pregnancy within 12 months. We used generalised estimating equations for clustered data to measure the intervention effect on contraceptive selection, and used survival analysis to assess pregnancy rates. FINDINGS Of 1500 women enrolled, more at intervention than control sites reported receiving counselling on IUDs or implants (565 [71%] of 797 vs 271 [39%] of 693, odds ratio 3·8, 95% CI 2·8-5·2) and more selected LARCs during the clinic visit (224 [28%] vs 117 [17%], 1·9, 1·3-2·8). The pregnancy rate was lower in intervention group than in the control group after family planning visits (7·9 vs 15·4 per 100 person-years), but not after abortion visits (26·5 vs 22·3 per 100 person-years). We found a significant intervention effect on pregnancy rates in women attending family planning visits (hazard ratio 0·54, 95% CI 0·34-0·85). INTERPRETATION The pregnancy rate can be reduced by provision of counselling on long-term reversible contraception and access to devices during family planning counselling visits. FUNDING William and Flora Hewlett Foundation.
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Affiliation(s)
- Cynthia C Harper
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, CA, USA.
| | - Corinne H Rocca
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, CA, USA
| | - Kirsten M Thompson
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, CA, USA
| | | | - Suzan Goodman
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, CA, USA
| | - Philip D Darney
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, CA, USA
| | - Carolyn L Westhoff
- Planned Parenthood Federation of America, New York, NY, USA; Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - J Joseph Speidel
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, CA, USA
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Steinauer JE, Upadhyay UD, Sokoloff A, Harper CC, Diedrich JT, Drey EA. Choice of the levonorgestrel intrauterine device, etonogestrel implant or depot medroxyprogesterone acetate for contraception after aspiration abortion. Contraception 2015; 92:553-9. [PMID: 26093190 DOI: 10.1016/j.contraception.2015.06.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [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: 02/07/2015] [Revised: 06/11/2015] [Accepted: 06/12/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Women who have abortions are at high risk of contraception discontinuation and subsequent unintended pregnancy. The objective of this analysis was to identify factors associated with choice of highly effective, long-acting, progestin-only contraceptive methods after abortion. STUDY DESIGN Women presenting for surgical abortion who selected the levonorgestrel intrauterine device (IUD), the progestin implant or the progestin injection (depot medroxyprogesterone acetate or DMPA) as their postabortion contraceptives were recruited to participate in a 1-year prospective cohort study. We used multivariable multinomial logistic regression to identify factors associated with choosing long-acting reversible contraceptives (IUD or implant) compared to DMPA. RESULTS A total of 260 women, aged 18-45 years, enrolled in the study, 100 of whom chose the IUD, 63 the implant and 97 the DMPA. The women were 24.9 years old on average; 36% were black, and 29% were Latina. Fifty-nine percent had had a previous abortion, 66% a prior birth, and 55% were undergoing a second-trimester abortion. In multivariable analyses, compared with DMPA users, women who chose the IUD or the implant were less likely to be currently experiencing intimate partner violence (IPV); reported higher stress levels; weighed more; and were more likely to have finished high school, to have used the pill before and to report that counselors or doctors were helpful in making the decision (all significant at p<.05, see text for relative risk ratios and confidence intervals.) In addition, women who chose the IUD were less likely to be black (p<.01), and women who chose the implant were more likely to report that they would be unhappy to become pregnant within 6 months (p<.05) than DMPA users. CONCLUSION A variety of factors including race/ethnicity, past contraceptive use, feelings towards pregnancy, stress and weight were different between LARC and DMPA users. Notably, current IPV was associated with choice of DMPA over the IUD or implant, implying that a desire to choose a hidden method may be important to some women and should be included in counseling. IMPLICATIONS In contraceptive counseling, after screening for IPV, assessing patient's stress and taking a history about past contraceptive use, clinicians should discuss whether these factors might affect a patient's choice of method.
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Affiliation(s)
- Jody E Steinauer
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, CA
| | - Ushma D Upadhyay
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, CA
| | - Abby Sokoloff
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, CA.
| | - Cynthia C Harper
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, CA
| | - Justin T Diedrich
- Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, MO
| | - Eleanor A Drey
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, CA
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