Medicaid Payment For Postpartum Long-Acting Reversible Contraception Prompts More Equitable Use

To increase access to highly effective contraception and improve reproductive autonomy, a growing number of state Medicaid programs pay for the provision of immediate postpartum long-acting reversible contraception (LARC) in addition to providing a global payment for maternity care. Using Pregnancy Risk Assessment Monitoring System data, we examined postpartum LARC use both overall and by race and ethnicity among respondents with Medicaid-paid births during the period 2012-18 in eight states that implemented immediate postpartum LARC payment and eight states without it. Using a quasi-experimental difference-in-differences design, we found that the policy resulted in an overall 2.1-percentage-point increase in postpartum LARC use. Our triple-differences analysis found no significant change among White mothers and a 3.7-percentage-point increase in use among Black mothers compared with White mothers. Additional research is needed to determine whether this increase was aligned with patients' preferences and whether hospitals' immediate postpartum LARC policies and practices take a patient-centered approach that supports reproductive autonomy and equity.

Building Blocks for the Long-acting and Permanent Contraceptives Coordinated Registry Network

Objectives

A multistakeholder expert group under the Women’s Health Technology Coordinated Registry Network (WHT-CRN) was organized to develop the foundation for national infrastructure capturing the performance of long-acting and permanent contraceptives. The group, consisting of representatives from professional societies, the US Food and Drug Administration, academia, industry and the patient community, was assembled to discuss the role and feasibility of the CRN and to identify the core data elements needed to assess contraceptive medical product technologies.

Design

We applied a Delphi survey method approach to achieve consensus on a core minimum data set for the future CRN. A series of surveys were sent to the panel and answered by each expert anonymously and individually. Results from the surveys were collected, collated and analyzed by a study design team from Weill Cornell Medicine. After the first survey, questions for subsequent surveys were based on the analysis process and conference call discussions with group members. This process was repeated two times over a 6-month time period until consensus was achieved.

Results

Twenty-three experts participated in the Delphi process. Participation rates in the first and second round of the Delphi survey were 83% and 100%, respectively. The working group reached final consensus on 121 core data elements capturing reproductive/gynecological history, surgical history, general medical history, encounter information, long-acting/permanent contraceptive index procedures and follow-up, procedures performed in conjunction with the index procedure, product removal, medications, complications related to the long-acting and/or permanent contraceptive procedure, pregnancy and evaluation of safety and effectiveness outcomes.

Conclusions

The WHT-CRN expert group produced a consensus-based core set of data elements that allow the study of current and future contraceptives. These data elements influence patient and provider decisions about treatments and include important outcomes related to safety and effectiveness of these medical devices, which may benefit other women’s health stakeholders.

Provision of fertility services to women in same-sex relationships at Catholic and non-Catholic clinics in the United States

INTRODUCTION

This study addressed deficient information on the provision of infertility care in obstetrics and gynecology clinics. We additionally evaluated the availability of these services based on clinic affiliations or stated sexual orientation.

METHODOLOGY

We performed a national cross-sectional "mystery caller" survey of 293 general obstetrics and gynecology clinics in 2017-2018. We matched clinics identified by web-based search engine in a 1:1 ratio by Catholic hospital affiliation, after determining number of clinics based on state-population densities. A standard call script included questions regarding provision of infertility services, ovulation induction methods, and information about the caller's sexual orientation. We performed descriptive frequencies and compared responses based on hospital affiliations.

RESULTS

Of the 293 clinics included, 49% were affiliated with Catholic and 17% with academic hospitals. The majority offered infertility care (85%, 248/293), and of these 97% (240/248) offered ovulation induction. Only 3% (6/240) reported they would not provide to women in same-sex relationships. Most clinics not offering infertility evaluations (43/45, 96%) cited it was outside of their scope of care and of these 33% (15/45) did not provide information for self-referral. Clinics affiliated with academic (aOR 0.23) or Catholic (aOR 0.34) hospitals were less likely to provide evaluations. Those with academic affiliation were more likely to provide information for self-referral (aOR 19.2).

DISCUSSION

Most general obstetrics and gynecology practices offered appointments for infertility evaluation and ovulation induction. Clinics rarely denied services to women reporting a same-sex partnership, regardless of hospital affiliation. These findings provide reassurance to same-sex couples seeking fertility care.

Concordance of Desired and Administered Postpartum Contraceptives among Emergency and Full Scope Medicaid Patients

OBJECTIVE

To determine if concordance of contraceptive preference and uptake differ between postpartum recipients of emergency versus full scope Medicaid.

STUDY DESIGN

We performed a historical cohort study of patients who delivered at a safety-net hospital in Denver, Colorado in 2016. In our public system, all patients had access to immediate postpartum tubal ligation and all forms of reversible contraception in outpatient clinics. We used data from electronic health records to compare contraceptive preferences and uptake between patients with full scope and emergency Medicaid at hospital discharge and by 12 weeks postpartum. We then compared contraceptive concordance (use of the same method as desired during delivery admission) between the groups at time of postpartum discharge and by 12 weeks postpartum.

RESULTS

We examined 693 women; 349 (50.1%) had emergency Medicaid and 344 (49.9%) had full scope Medicaid. The mean age at delivery was 27.9 years, and most patients were Hispanic (74%). Women with emergency Medicaid were less likely to receive their desired method of postpartum contraception before hospital discharge (53.6% vs. 66.9%; p < .01). One-half of the patients with emergency Medicaid who did not receive their desired method of immediate postpartum contraception were unable to obtain it based on insurance ineligibility. By 12 weeks postpartum, the rates of concordance did not differ by insurance status: 52.4% of patients with emergency Medicaid and 55.2% of patients with full scope Medicaid received their desired method of contraception (p = .46).

CONCLUSIONS

Emergency Medicaid recipients, largely recent and/or unauthorized immigrants, have high demand for highly effective postpartum contraceptives. Although emergency Medicaid recipients initially had lower rates of receipt of their desired contraceptive during the hospital stay compared with those with full scope Medicaid, they ultimately had similar concordance rates by 12 weeks postpartum. We suspect this finding was in part due to free access to all methods of contraception in our outpatient clinics during the postpartum course. Systemic barriers should be reduced to ensure better access to postpartum contraceptives for all patients, regardless of insurance coverage, to improve reproductive equity.

Assessing adverse event reports of hysteroscopic sterilization device removal using natural language processing

OBJECTIVE

To develop an annotation model to apply natural language processing (NLP) to device adverse event reports and implement the model to evaluate the most frequently experienced events among women reporting a sterilization device removal.

METHODS

We included adverse event reports from the Manufacturer and User Facility Device Experience database from January 2005 to June 2018 related to device removal following hysteroscopic sterilization. We used an iterative process to develop an annotation model that extracts six categories of desired information and applied the annotation model to train an NLP algorithm. We assessed the model performance using positive predictive value (PPV, also known as precision), sensitivity (also known as recall), and F₁ score (a combined measure of PPV and sensitivity). Using extracted variables, we summarized the reporting source, the presence of prespecified and other patient and device events, additional sterilizations and other procedures performed, and time from implantation to removal.

RESULTS

The overall F₁ score was 91.5% for labeled items and 93.9% for distinct events after excluding duplicates. A total of 16 535 reports of device removal were analyzed. The most frequently reported patient and device events were abdominal/pelvic/genital pain (N = 13 166, 79.6%) and device dislocation/migration (N = 3180, 19.2%), respectively. Of those reporting an additional sterilization procedure, the majority had a hysterectomy or salpingectomy (N = 7932). One-fifth of the cases that had device removal timing specified reported a removal after 7 years following implantation (N = 2444/11 293).

CONCLUSIONS

We present a roadmap to develop an annotation model for NLP to analyze device adverse event reports. The extracted information is informative and complements findings from previous research using administrative data.

Influence of a values clarification workshop on residents training at Catholic Hospital programs

Objectives

To evaluate if a values clarification workshop conducted at Catholic hospital training programs influenced obstetrics and gynecology residents' abortion attitudes.

Study design

Between 2018 and 2019, we provided a values clarification workshop focused on abortion care to 47 obstetrics and gynecology residents at five Catholic programs that do not provide abortion training. Participants received a pre-survey eliciting participant characteristics, and training experiences. On pre- and post-surveys, we asked participants to respond to abortion scenarios using a five-point Likert scales (1 = strongly disagree, 2 = somewhat disagree 3 = neither agree nor disagree, 4 = somewhat agree, 5 = strongly agree). We calculated descriptive frequencies, report the proportions agreeing with the statements (Likert ≥ 4) before and after the workshop, and compared median Likert responses using Wilcoxon matched pair test.

Results

Forty-one participants (87%) completed both surveys. Twelve (29%) reported Catholic religion, six (15%) reported their personal reproductive care views were in line with their institution, and five (12%) selected their program based on its religious affiliation. Three (9%) had experience with first-trimester abortion for nonmedical reasons, and 20 (49%) planned to provide such care after graduation. Both before and after the workshop, all participants could think of a justification why a patient with an undesired pregnancy would choose abortion. After the workshop, more residents were able to think of a justifiable reason for the following abortion-related scenarios: (1) patients declining post-abortal contraception (51% vs. 78%, p < 0.001), (2) patients presenting for subsequent abortion (93% vs 95%, p = 0.01), and (3) patients presenting for second-trimester abortion (93% vs. 100%, p = 0.001). Many participants increased their Likert score when asked about acceptability of patients declining post-abortal contraception (n = 24, 59%), patients seeking a subsequent abortion (n = 15, 37%), and patients obtaining a second trimester abortion contraception (n = 11, 27%). Emotional and professional reactions to these scenarios were unchanged. After the workshop, residents were more likely to consider either financial inability (73% vs. 83%, p < 0.01) or disruption to career or education (71% vs 80%, p < 0.01) as morally acceptable reasons for requesting an abortion. For abortion for a patient who is financially unable to support their child, 12 (29%) increased their Likert score, 1 (2%) had a lower score and the remaining 28 (68%) had no change. For abortion for a patient whose career or education would be disrupted 13 (32%) increased their Likert score, one (2%) had a lower score and the remaining 27 (66%) had no change.

Conclusion

Our values clarification workshop resulted in more residents at Catholic training programs endorsing accepting attitudes toward abortion patient scenarios. Values clarification exercises can be a useful tool for residents to discuss abortion care, especially when training is insufficient.

Implications

Most obstetrics and gynecology residents at Catholic hospitals experience limited training in abortion care. A values clarification workshop conducted at such programs may result in increasing resident acceptance of abortion-related patient care scenarios and may help reduce abortion stigma.

Integration of Catholic Values and Professional Obligations in the Provision of Family Planning Services: A Qualitative Study

IMPORTANCE

Religious leaders of the Catholic church created guidelines for practicing medicine, that involve reproductive care restrictions that may conflict with professional obligations.

OBJECTIVE

To explore how Catholic obstetrician-gynecologists integrate their religious values and professional obligations related to family planning services.

DESIGN, SETTING, AND PARTICIPANTS

In this qualitative investigation, in 2018, US-based obstetrician-gynecologists were recruited through an online survey and were invited to participate in audio-recorded telephone interviews using a semistructured interview guide. Participants were obstetrician-gynecologists who self-identified as Catholic and reported providing reproductive health care as follows: (1) provide natural family planning only (low practitioners), (2) provide additional contraceptive methods (moderate practitioners), and (3) provide family planning services including abortion (high practitioners). The study purposively sampled those with higher self-reported religiosity. Data were analyzed from November 2018 to February 2019.

MAIN OUTCOMES AND MEASURES

The primary outcome was understanding how participants describe integration of Catholic values with family planning service provision. The telephone interviews explored their integration of Catholic values and professional obligations, and 3 coders analyzed the responses using grounded theory.

RESULTS

Among the 34 Catholic obstetrician-gynecologists interviewed (27 women [79.4%]), there were 10 low, 15 moderate, and 9 high practitioners from 19 states. Participants' description of morality was consistent with Albert Bandura's Social-Cognitive Theory of Moral Thought and Action. The findings were used to create a modified framework. Within each group of physicians, 3 themes demonstrating their reconciliations between Catholic values and professional obligations emerged; each of these themes reflected one of the medical ethical principles of autonomy, beneficence, nonmaleficence, or justice. All 10 low practitioners primarily promoted natural family planning approaches to avoid iatrogenic risks and none provided abortion, reflecting nonmaleficence. Alternatively, moderate practitioners focused on nonmaleficence by offering contraception to prevent abortions. High practitioners primarily promoted patient autonomy by separating religious doctrine from medical practice. All had concerns for beneficence. In each group, 1 of the 4 medical ethical principles was underrepresented.

CONCLUSIONS AND RELEVANCE

In this qualitative analysis, Catholic obstetrician-gynecologists establish their family planning care provision practices by emphasizing certain moral and/or ethical principles over others. These findings highlight how physician morality in the realm of family planning service provision often involves certain religious and/or professional reconciliations. Understanding the dilemmas Catholic obstetrician-gynecologists face can guide professional development efforts and inform ongoing discussions about conscientious objection and provision.

Identification of obstetric anal sphincter injuries (OASIs) and other lacerations: a national survey of nurse-midwives

INTRODUCTION AND HYPOTHESIS

Clinical quality improvement relies on accurate understanding of current practice. We performed a cross-sectional national survey of certified nurse-midwives (CNMs) assessing classification and identification of obstetric anal sphincter injury (OASI) and other delivery lacerations. We hypothesized laceration diagnoses are frequently inaccurate, and delivery records for obstetric lacerations may be of questionable quality.

METHODS

We emailed 6909 American College of Nurse Midwives members an internet-based survey link. Of respondents, we included clinically active CNMs who perform at least one delivery per month. We evaluated laceration knowledge and application using standard descriptive text and images and asked about processes for recording lacerations in the delivery record.

RESULTS

We received 1070 (15.5%) completed surveys and 832 (77.8%) met inclusion criteria. Over 50% characterized their OASI training and ability to identify OASI as good/excellent. Most (79%) had never attended education review on OASI. The overall accuracy for classification and identification of perineal lacerations ranged from 49 to 99%. Non-perineal lacerations were frequently categorized using the perineal/OASI system. Half of respondents (51%) document their deliveries in an electronic medical record but a quarter (28%) are not personally responsible for approving delivery data. Younger participants without a doctoral degree, with self-assessed good/excellent laceration training, and caring for < 50% publicly insured patients had higher accuracy for laceration identification and diagnosis.

CONCLUSIONS

We found high rates of inaccurate laceration diagnosis and inappropriate application of the perineal OASI degree system, suggesting education and training are needed. Clinical studies that rely on delivery diagnosis of OASI may not be reliable.

A pilot study on the effect of isotretinoin on serum etonogestrel concentrations in contraceptive implant users

OBJECTIVE

To explore the pharmacokinetic interaction between isotretinoin, a cytochrome P-450 (CYP) inducer and potent teratogen, and the etonogestrel contraceptive implant.

STUDY DESIGN

We enrolled healthy reproductive-age women initiating isotretinoin and using an etonogestrel implant. We compared serum etonogestrel concentrations at baseline and after four and nine weeks of isotretinoin co-administration using a validated assay.

RESULTS

Among eight implant users, all serum etonogestrel concentrations remained >90 pg/mL during isotretinoin co-administration with no significant changes from baseline (p = 0.25, Friedman's test).

CONCLUSION

In this exploratory study, we found that isotretinoin did not cause serum etonogestrel concentrations to fall below the threshold for ovulatory suppression (<90 pg/mL) among implant users.

IMPLICATIONS

Reproductive-age women treated with isotretinoin require reliable contraception to prevent pregnancies impacted by teratogenic-effects. This small study demonstrates that contraceptive implant users maintained serum etonogestrel concentrations above the threshold for consistent ovulatory suppression during isotretinoin co-administration. The contraceptive implant remains an appropriate option for patients considering isotretinoin therapy.

Satisfaction with medication abortion and marijuana use: A prospective cohort study

OBJECTIVES

This exploratory study compared self-reported satisfaction rates and pain scores between patients who used marijuana during their medication abortion versus non-users.

STUDY DESIGN

We recruited medication abortion patients at a University-affiliated abortion clinic in Denver, Colorado. Participants completed a pre-abortion questionnaire, pain diary, and follow-up survey that assessed satisfaction with pain control, symptoms, and abortion experience. Using medians test, we compared the sums of median satisfaction scores between patients who used marijuana versus non-users. Based on diary entries, we also compared reported pain over 24 h after misoprostol (area under the curve [AUC]) between cohorts.

RESULTS

We enrolled 51 participants; 16 marijuana users and 35 non-marijuana users. Marijuana users and non-users had similar sums of median satisfaction scores (22 vs. 20 out of 30, p = 0.90) and median question-specific satisfaction scores (range 7-8 vs. 6.5-8, p = 0.6-1.0). Sixteen marijuana users (100%) and 20 (57%) non-users completed their pain diary; median AUCs for pain were similar (65.0 vs. 59.5, p = 0.73). Thirteen (81%) patients subjectively correlated marijuana use with pain reduction, seven (44%) with anxiety reduction, and six (38%) with nausea/vomiting improvement.

CONCLUSIONS

We found no significant difference in measures of medication abortion satisfaction and pain when comparing marijuana users to non-users. However, marijuana users often attributed symptom improvement during their medication abortion to marijuana use.

IMPLICATIONS

Until randomized studies are available, clinicians can counsel patients that marijuana use may not necessarily affect satisfaction or pain with medication abortion. It remains unknown whether marijuana has potential benefits in a marijuana-naïve population undergoing medication abortion. Future studies should explore the role that marijuana and its derivatives may play for pain and side effect management during medication abortion among marijuana-naïve patients.

Religious refusals to long-acting reversible contraceptives in Catholic settings: a call for evidence

No-cost contraceptive provisions as in the Affordable Care Act have substantially reduced the financial burdens that patients previously faced with long-acting reversible contraception (LARC) access. Such efforts have contributed to improved LARC uptake and substantial declines in unintended pregnancy and abortion rates. However, governmental protections that allow religious restrictions to care to be implemented at institutional and systemic levels currently limit equitable access by healthcare consumers. A significant proportion of the US healthcare market is controlled by Catholic healthcare systems, which use moral teachings to inform guidelines to care. Many patients do not realize that their healthcare choices will be affected by attendance at a Catholic institution, in part because such facilities do little to inform patients of restrictions to common reproductive services including LARC. Limited data demonstrate that often hormonal intrauterine devices are provided through workarounds, but that implants and copper intrauterine devices are rarely available or approved in Catholic settings. The scarcity of data, particularly on patient outcomes, is in part explained by research barriers within Catholic settings. This Call for Action sets forth the notion that we should no longer remain complicit with allowances for institutional religious refusals of care unless we understand medical and ethical outcomes.

Family planning training at Catholic and other religious hospitals: a national survey

BACKGROUND

Catholic and other faith-based hospitals often restrict family planning service provision based on institutional doctrine. Approximately 11% of US accredited obstetrics and gynecology residency programs occur at such hospitals, creating a challenge to educational leaders who must ensure comprehensive family planning training.

OBJECTIVE

To evaluate and summarize family planning training at obstetrics and gynecology residency programs that are affiliated with Catholic and other faith-based hospitals that restrict reproductive services.

MATERIALS AND METHODS

Using an online database search and survey screening questions, we identified 30 of 278 accredited 2017-2018 programs in which at least 70% of resident time is spent in faith-based hospitals that restrict family planning services; Jewish programs were excluded. We queried program leaders between March 2017 and April 2018 about education and training using an online or paper survey, and asked them to report on training settings, provision of family planning services in such settings, and to rate aspects of training as "poor," "adequate," or "strong." We compared responses at Catholic versus other faith-based programs using Fisher exact tests, χ² analyses, and median tests.

RESULTS

Among 30 programs, 25 responded (83%); the majority of respondents were program directors (88%) and represented Catholic hospitals (76%). All reported adequate contraceptive training, with 47% of Catholic programs relying on off-site locations. The majority of Catholic sites (84%) relied on off-site sterilization training sites. Survey respondents from Catholic programs most commonly endorsed concerns for inadequate training in postpartum tubal ligations (53% of Catholic respondents versus 0% of other faith-based program respondents, P = .05). Approximately one-half (56%) offered abortion training as part of the curriculum ("routine"), 32% offered residents the opportunity to arrange training ("elective"), and 12% did not offer; the majority (84%) relied on off-site collaborations. Catholic sites were more likely than other religious programs to report poor abortion training (47% versus 0%, P = .04). Five Catholic programs (26% of Catholic programs) reported that their residents did not meet the graduate training requirement for completion of 20 dilation and curettage procedures. One-third reported a prior Residency Review Committee family planning citation(s), and many commented that these citations helped provide leverage for improved training.

CONCLUSION

Although Catholic and other restrictive, faith-based obstetrics and gynecology residency training programs have developed strategies in response to institutional restrictions, many report ongoing deficiencies, and almost one-half reported they were noncompliant with abortion training requirements. Programs with deficient trainings may benefit from strategic approaches, including enhanced onsite education and collaborations with off-site facilities.

Patient Views on Religious Institutional Health Care

IMPORTANCE

Federal protections allow health facilities to limit options to patients on the basis of religious values. Little is known about whether US adults consider religious affiliation when selecting facilities and whether they agree with such limitations.

OBJECTIVE

To understand patient views on religious institutional care.

DESIGN, SETTING, AND PARTICIPANTS

This is a population-based, cross-sectional survey study of US adults recruited from the probability-based AmeriSpeak Omnibus panel available from NORC (formerly the National Opinion Research Center) at the University of Chicago. Surveys were administered via internet or telephone during a 3-day fielding period in November 2017. Data analysis was performed from January 2018 to October 2019.

EXPOSURES

Participant characteristics, including religiosity measures.

MAIN OUTCOMES AND MEASURES

Whether patients consider religious affiliation when selecting a health care facility and their views on whether an institution's religious values should take precedence over their health choices. Responses were compared by gender. When gender differences existed, regression models were performed, and thematic content analysis was applied to open-ended responses.

RESULTS

There were 1446 participants (745 [51.5%] male; mean [SD] age, 46 [17] years), for a survey completion rate of 24.5% and weighted cumulative response weight of 7.3%. Most respondents (62.6%) were white, and the most common religion was Protestant (28.2%). When specifically asked, only 6.4% reported that they considered religious affiliation when selecting a health care facility; most participants (71.3%) reported when selecting a health care facility that they did not care whether it is religiously affiliated, 13.4% preferred a religious affiliation, and 15.3% preferred no religious affiliation. There were no gender differences. Most participants (71.4%) believed that their health choices should take priority over an institution's religious affiliation in services offered, and this was more common for women than for men (74.9% vs 68.1%; difference, 6.8%; 95% CI, 5.6%-8.2%; P = .005), who more commonly endorsed concerns for personal choice and autonomy over one's own body.

CONCLUSIONS AND RELEVANCE

This study suggests that most patients value their personal choices, yet do not consider an institution's religious affiliation when choosing their source of health care. Women placed greater emphasis on their autonomy in comparison with an institution's right to invoke religious restrictions to care. Given the growth in ownership of health care facilities by religious entities in the United States and increasing attention to conscientious objections, these findings point to a need for advocacy and legislation that effectively balances protections for religious institutions with protections for patients.

Women's Expectation of Receiving Reproductive Health Care at Catholic and Non-Catholic Hospitals

CONTEXT

Catholic hospitals operate under directives that prohibit the provision of contraceptives, sterilization and abortion. Little research has examined women's awareness of these institutions' policies, which affects their ability to make informed decisions about where to seek care.

METHODS

In 2016, some 1,430 women aged 18-45 were recruited from a U.S. probability-based research panel for a survey about hospital care. Respondents were randomized to a hypothetical Catholic or nonreligious hospital group and asked about their expectations for receiving nine specific reproductive services. Multivariable logistic regression analyses were used to evaluate associations between participants' characteristics and their correctly identifying a hospital as Catholic, as well as between characteristics and expecting that birth control pills, tubal ligation or abortion for serious fetal indications would be provided there.

RESULTS

Women randomized to the Catholic hospital group were less likely than those randomized to the nonreligious group to expect provision of birth control pills (77% vs. 86%), tubal ligation (70% vs. 78%) or abortion for serious fetal indications (42% vs. 54%). Income level was associated with correctly identifying the Catholic hospital: Compared with individuals with the lowest income, those in three of the four other income groups were more likely to identify the hospital as Catholic (odds ratios, 1.9-2.2). In comparison with women who misidentified the Catholic hospital, those who identified it as Catholic had lower expectations that the hospital would provide birth control pills (0.3), tubal ligation (0.5) or abortion (0.2).

CONCLUSIONS

Many women do not realize the breadth of restrictions on reproductive health care at Catholic hospitals. Without institutional transparency, patient autonomy and health outcomes may be compromised.

Relationship between patient characteristics and serum etonogestrel concentrations in contraceptive implant users

OBJECTIVE

To determine whether serum etonogestrel concentrations in contraceptive implant users are associated with certain individual patient characteristics.

STUDY DESIGN

We enrolled reproductive-age women using etonogestrel contraceptive implants between 12-36 months duration and measured a single serum etonogestrel concentration. Participants also completed a questionnaire about demographics.

RESULTS

We enrolled 350 participants; median age was 22.5 years (range 18.0-39.1), median months of implant use was 26.0 (range 12.0-36.0), and median body mass index was 25.7 kg/m² (range 18.5-52.0). Our study population was primarily white/Caucasian (46.6% [163/350]) and Hispanic/Latina ethnicity (51.4% [180/350]). The median serum etonogestrel concentration was 137.4 pg/ml and etonogestrel concentrations varied 12.4 fold in the population (range 55.8-695.1 pg/ml). Using forward stepwise linear regression, months of implant use (β=-1.74, p<.001) and body mass index (β=-3.10, p<.001) were both significantly associated with decreased serum etonogestrel concentration with Black/African American race as a positive effect modifier (β=18.24, p=.099); R-squared for the model=0.13.

CONCLUSIONS

Individuals demonstrated a wide variability in serum etonogestrel concentrations, which can potentially affect side-effect profiles and efficacy. Increasing body mass index and longer duration of implant use were associated with small decreases in serum etonogestrel concentrations, while self-reported Black/African American race was associated with a non-significant increase. Despite these findings, most of etonogestrel variability was unaccounted for, suggesting that other clinical, pharmacologic, and genetic factors contributing to variability in etonogestrel concentrations remain to be determined.

IMPLICATIONS

Although increases in body mass index are associated with lower etonogestrel levels in contraceptive implant users, the majority of women will maintain serum concentrations that consistently suppress ovulation. Furthermore, certain patient characteristics can only explain a small portion (13%) of the variability in serum etonogestrel levels among contraceptive implant users.

Disclosure of Religious Identity and Health Care Practices on Catholic Hospital Websites

This study examines whether Catholic hospitals disclose their religious identity and health care practices based on the church’s teachings on their websites.

Prevention and Management of Severe Obstetric Anal Sphincter Injuries (OASIs): a National Survey of Nurse- Midwives

INTRODUCTION AND HYPOTHESIS

There are no data on midwives' knowledge and management of obstetric anal sphincter injuries (OASIs) in the USA. We performed a cross-sectional national survey characterizing OASI practice by certified nurse midwives (CNMs), hypothesizing that few midwives personally repair OASIs and that there are gaps in CNM OASI training/education.

METHODS

We emailed a REDCap internet-based survey to 6909 American College of Nurse Midwives members (ACNM). We analyzed responses from active clinicians performing at least one delivery per month, asking about OASI risks, prevention, repair, and management. We summarized descriptive data then evaluated OASI knowledge by patient and provider characteristics.

RESULTS

We received 1070 (15.5%) completed surveys, and 832 (77.8%) met the inclusion/exclusion criteria. Participants were similar to ACNM membership. Respondents most frequently identified prior OASI (87%) and nutrition (71%) as antepartum OASI risk factors and, less frequently, nulliparity (36%) and race (22%). Identified intrapartum risks included forceps delivery (94%) and midline episiotomy (88%). When obstetric laceration is suspected, 13.6% of respondents perform a rectal examination routinely. Only 15% of participants personally perform OASI repair. Overall, participants matched 64% of evidence-based answers. OASI education/training courses were attended by 30% of respondents, and 44% knew of OASI protocols within their group/institution. Of all factors evaluated, the percent of evidence-based responses was only different for respondent education/CME and protocols.

CONCLUSIONS

Quality initiatives regarding OASI prevention and management may improve care. Our data suggest OASI training for midwives may improve delivery care in the US. Further studies of other obstetric providers are needed.

Ongoing Etonogestrel Contraceptive Implant Use Throughout Pregnancy

Case reports of pregnancies with inadvertent etonogestrel contraceptive implant exposure in the first-trimester have not demonstrated teratogenic risks or adverse pregnancy outcomes. We report the clinical observations of a 15-year-old nulligravida who continued her etonogestrel contraceptive implant throughout pregnancy and delivery, without any adverse maternal or neonatal outcomes. The patient then continued her contraceptive implant as a reliable postpartum contraceptive method. Although her favorable outcomes are consistent with available pharmacologic literature, more data is needed regarding maintenance of a contraceptive implant during a desired pregnancy.

What Are Women Told When Requesting Family Planning Services at Clinics Associated with Catholic Hospitals? A Mystery Caller Study

CONTEXT

Catholic Church directives restrict family planning service provision at Catholic health care institutions. It is unclear whether obstetrics and gynecology clinics that are owned by or have business affiliations with Catholic hospitals offer family planning appointments.

METHODS

Mystery callers phoned 144 clinics nationwide that were found on Catholic hospital websites between December 2014 and February 2016, and requested appointments for birth control generally, copper IUD services specifically, tubal ligation and abortion. Chi-square and Fisher's exact tests assessed potential correlates of appointment availability, and multivariable logistic regressions were computed if bivariate testing suggested multiple correlates.

RESULTS

Although 95% of clinics would schedule birth control appointments, smaller proportions would schedule appointments for copper IUDs (68%) or tubal ligation (58%); only 2% would schedule an abortion. Smaller proportions of Catholic-owned than of Catholic-affiliated clinics would schedule appointments for birth control (84% vs. 100%), copper IUDs (4% vs. 97%) and tubal ligation (29% vs. 72%); for birth control and copper IUD services, no other clinic characteristics were related to appointment availability. Multivariable analysis confirmed that tubal ligation appointments were less likely to be offered at Catholic-owned than at Catholic-affiliated clinics (odds ratio. 0.1); location and association with one of the top 10 Catholic health care systems also were significant.

CONCLUSIONS

Adherence to church directives is inconsistent at Catholic-associated clinics. Women visiting such clinics who want highly effective methods may need to rely on less effective methods or delay method uptake while seeking services elsewhere.

Impact of Catholic Hospital Affiliation During Obstetrics and Gynecology Residency on the Provision of Family Planning

BACKGROUND

Catholic hospitals operate under the Ethical and Religious Directives for Catholic Health Care Services, which for obstetrics and gynecology residents may create barriers to receiving adequate training in family planning.

OBJECTIVE

We evaluated how training at a Catholic hospital affects trainees' subsequent provision of reproductive health services at secular institutions.

METHODS

This qualitative study used semistructured interviews with recent obstetrics and gynecology graduates in generalist practice at secular institutions. We queried about their training experiences, perceived deficiencies, and current provision of family planning services. Three researchers independently coded transcripts, using grounded theory.

RESULTS

We reached thematic saturation after 15 of 31 graduates (48%) from 7 Catholic hospital residencies participated in interviews between June 2014 and February 2015. Many participants reported a lack of awareness regarding limitations on this aspect of their training. All participants reported reproductive health care training deficiencies, and many explained that "elective" training required resident initiative to obtain. After graduation, participants reported dissatisfaction with training in family planning, delayed competency in this area, and a lack of ability to provide certain family planning procedures. All felt that Catholic programs should improve family planning training by providing routine, opt-out family planning opportunities.

CONCLUSIONS

Obstetricians and gynecologists who trained at Catholic institutions felt that religion-based policies negatively affected their training experiences and the range of reproductive health services they subsequently provide in practice. Forming collaborations with off-site facilities, particularly for postpartum tubal ligation and uterine evacuation, may improve the reproductive care these physicians ultimately provide to women.

Motivating factors for dual-method contraceptive use among adolescents and young women: a qualitative investigation

OBJECTIVE

This qualitative study explores how adolescents and young women perceive the need for and describe the use of dual method contraception.

STUDY DESIGN

We interviewed 20 sexually active women aged 16-24 who attended an adolescent-focused Title X family-planning clinic and were using a non-barrier contraceptive method. We used a semi-structured interview guide that included domains related to sexual activity, knowledge of and use of contraceptives and condoms, and relationship factors. We coded transcripts using grounded theory techniques and used an iterative process to develop overarching themes.

RESULTS

Dual method contraceptive users primarily discussed pregnancy prevention as their motivating factor. Many expressed anxieties over an unplanned pregnancy and reported condom use as "back-up" contraception. Risk perception for pregnancy or STI acquisition did not necessarily change as relationship trust increased, but rather, their anxiety regarding the negativity of such outcomes decreased. Dual-method contraception use decreased when participants reported that condoms were not readily available, or when they self-described immaturity. Less frequently, participants reported dual method use for sexually transmitted infection (STI) prevention, and many substituted STI testing for condom use. Contraceptive type (short-acting vs. long-acting) did not influence reported attitudes towards dual method use.

CONCLUSION

Health educators and clinicians encourage condom use in young women due to the significant morbidity associated with STI acquisition. Most participants in our study view condoms as a way to improve pregnancy prevention. Acknowledging and addressing this divergence in motivation will allow caregivers to improve strategies for communicating the importance of dual method use.

IMPLICATIONS

Young women primarily describe pregnancy prevention as the reason for dual method use, STI protection is less salient. Consideration of this viewpoint by health educators and clinicians will allow us to communicate more effectively to prevent STI morbidity.

Reproductive Health Abstracts (2004-2010) What Gets Published?

OBJECTIVE

To determine the manuscript publication rate and associated predictors of publication for abstracts submitted to the Reproductive Health Conference from 2004-2010.

STUDY DESIGN

We re- viewed all abstracts and determined publication. We identified and analyzed as- sociated factors potentially related to publication.

RESULTS

We reviewed 577 abstracts: 142 oral presenta- tions (25%) and 435 poster presentations (75%). The majority were published (58%). Abstracts that were published had a higher average number of abstract authors: published abstracts mean=4.26, standard deviation (SD)=1.7, vs. unpub- lished abstracts mean=3.78, SD=1.9 (p=0.001). Multivariable analysis found oral presentation (odds ratio [OR) =2.1, 95% confidence interval [CII 1.4-3.2), high- volume authorship (defined as an author who was listed on >6 abstracts) (OR=1.6, 95% CI 1.1-2.3), and pro- spective study design (OR=1.4, 95% CI 1.0-2.0) to be independent predictors of publication.

CONCLUSION

A high percentage of the abstracts selected by the Reproductive Health abstract selection committees are likely to be published, and thus it is an important venue for the dissemination of cutting-edge research.

Adolescent and Young Women's Contraceptive Decision-Making Processes: Choosing "The Best Method for Her"

PURPOSE

To evaluate influences on adolescent and young women's contraceptive decision-making processes.

METHODS

We conducted 21 individual interviews with women who presented to an adolescent-focused Title X family planning clinic seeking a new contraceptive method. Data were collected using a semi-structured interview guide, audio-taped and transcribed. Three researchers independently coded the transcripts using grounded theory; codes were organized into overarching themes and discrepancies were resolved.

RESULTS

After identification of themes, we organized the conceptual framework of the decision-making process using the transtheoretical model of behavior change in which participants move through 4 stages: (1) contemplation, (2) preparation, (3) action, and (4) maintenance. When contemplating contraception, most of our participants were highly motivated to avoid pregnancy. During preparation, participants gathered information related to their contraceptive concerns. Participants cited peers as primary informants and healthcare providers as experts in the field. Participants integrated information received with their personal concerns about contraception initiation; the most common concerns were effectiveness, method duration, convenience, and side effects. When participants acted on choosing a contraceptive method they described how it fit their individual needs. They considered their contraceptive experiences unique and not necessarily applicable to others. During maintenance, they acted as informants for other peers, but most commonly expressed that each individual must choose "the best method for her."

CONCLUSIONS

When adolescent and young women select a contraceptive method they balance the benefits and risks of available methods portrayed by peers and provider in the context of their personal concerns. Peer influence appeared to be greatest when participants shared contraceptive concerns and goals.

Safety of first-trimester uterine evacuation in the outpatient setting for women with common chronic conditions

OBJECTIVE

We compared complications of outpatient first-trimester uterine evacuation between women with medical comorbidities and healthy peers.

STUDY DESIGN

We examined the medical histories and procedure outcomes of women receiving first-trimester uterine evacuations between 01/02/2009 and 03/07/2014. We compared women without medical problems to those reporting diabetes, hypertension, obesity (body mass index ≥30.0 or weight ≥200 lbs), HIV, epilepsy, asthma, thyroid disease and/or bleeding/clotting disorders. We compared incidence of any of the following: resuction, uterine perforation, estimated blood loss >100 cc and cervical laceration.

RESULTS

A total of 1960 women met inclusion criteria; 597 (30%) had ≥1 comorbidity. When compared to women without medical morbidities, women with common chronic conditions were older (28.3±6.7 vs. 27.3±6.7 years, p<.01), less likely to be primigravid (29.1% vs. 35.7%, p<.01) and more likely to have had a prior cesarean delivery (24.9% vs. 15.7%, p<.001). Gestational age and indication for evacuation were similar for the groups. The overall complication rate was 2.9%. There was no difference in complications between the group of patients with at least one comorbidity compared to the group of women without any comorbidity (OR=0.9, 95% CI 0.5, 1.6). Additionally, there were no specific medical comorbidities that led to an increased complication rate. The only significant predictor of complication was history of cesarean delivery (OR=1.9, 95% CI 1.1, 3.4).

CONCLUSION

Women with common chronic conditions undergoing outpatient first-trimester uterine evacuation do not appear to be at greater risk of complications compared to healthy peers. While a careful medical history is always required, providers may feel reassured that complications remain infrequent.

IMPLICATIONS

Women with common chronic conditions undergoing outpatient first-trimester uterine evacuation do not appear to be at greater risk of complications compared to healthy peers.

Enablers of and barriers to abortion training

BACKGROUND

Since the legalization of abortion services in the United States, provision of abortions has remained a controversial issue of high political interest. Routine abortion training is not offered at all obstetrics and gynecology (Ob-Gyn) training programs, despite a specific training requirement by the Accreditation Council for Graduate Medical Education. Previous studies that described Ob-Gyn programs with routine abortion training either examined associations by using national surveys of program directors or described the experience of a single program.

OBJECTIVE

We set out to identify enablers of and barriers to Ob-Gyn abortion training in the context of a New York City political initiative, in order to better understand how to improve abortion training at other sites.

METHODS

We conducted in-depth qualitative interviews with 22 stakeholders from 7 New York City public hospitals and focus group interviews with 62 current residents at 6 sites.

RESULTS

Enablers of abortion training included program location, high-capacity services, faculty commitment to abortion training, external programmatic support, and resident interest. Barriers to abortion training included lack of leadership continuity, leadership conflict, lack of second-trimester abortion services, difficulty obtaining mifepristone, optional rather than routine training, and antiabortion values of hospital personnel.

CONCLUSIONS

Supportive leadership, faculty commitment, and external programmatic support appear to be key elements for establishing routine abortion training at Ob-Gyn residency training programs.

Training at a faith-based institution matters for obstetrics and gynecology residents: results from a regional survey

BACKGROUND

Prior data suggest that opportunities in family planning training may be limited during obstetrics and gynecology (Ob-Gyn) residency training, particularly at faith-based institutions with moral and ethical constraints, although this aspect of the Ob-Gyn curriculum has not been formally studied to date.

OBJECTIVES

We compared Ob-Gyn residents' self-rated competency and intentions to provide family planning procedures at faith-based versus those of residents at non-faith-based programs.

METHODS

We surveyed residents at all 20 Ob-Gyn programs in Illinois, Indiana, Iowa, and Wisconsin from 2008 to 2009. Residents were queried about current skills and future plans to perform family planning procedures. We examined associations based on program and residents' personal characteristics and performed multivariable logistic regression analysis.

RESULTS

A total of 232 of 340 residents (68%) from 17 programs (85%) returned surveys. Seven programs were faith-based. Residents from non-faith-based programs were more likely to be completely satisfied with family planning training (odds ratio [OR]  =  3.4, 95% confidence limit [CI], 1.9-6.2) and to report they "understand and can perform on own" most procedures. Most residents, regardless of program type, planned to provide all surveyed family planning services.

CONCLUSIONS

Despite similar intentions to provide family planning procedures after graduation, residents at faith-based training programs were less satisfied with their family planning training and rate their ability to perform family planning services lower than residents at non-faith-based training programs.