Sex, gender, and pronoun self-identification among obstetrics and gynecology patients

Among patients surveyed at an academic Obstetrics/Gynecology clinic, 4.8% self‐identified as gender diverse. Gender diversity was not associated with reported comfort at the visit.

The association between abortion restrictions and patient-centered care for early pregnancy loss at US obstetrics-gynecology residency programs

BACKGROUND

Early pregnancy loss is a common medical problem, and the recommended treatments overlap with those used for induced abortions. The American College of Obstetricians and Gynecologists recommends the incorporation of clinical and patient factors when applying conservative published imaging guidelines to determine the timing of intervention for early pregnancy loss. However, in places where abortion is heavily regulated, clinicians who manage early pregnancy loss may cautiously rely on the strictest criteria to differentiate between early pregnancy loss and a potentially viable pregnancy. The American College of Obstetricians and Gynecologists also notes that specific treatment modalities that are frequently used to induce abortion, including the use of mifepristone in medical therapy and surgical aspiration in an office setting, are cost-effective and beneficial for patients with early pregnancy loss.

OBJECTIVE

This study aimed to determine how US-based obstetrics and gynecology residency training institutions adhere to the American College of Obstetricians and Gynecologists recommendations for early pregnancy loss management, including the timing and types of interventions, and to evaluate the relationship with institutional and state abortion restrictions.

STUDY DESIGN

From November 2021 to January 2022, we conducted a cross-sectional study of all 296 US-based obstetrics and gynecology residency programs by emailing them and requesting that a faculty member complete a survey about early pregnancy loss practices at their institution. We asked about location of diagnosis, use of imaging guidelines before offering intervention, treatment options available at their institution, and program and personal characteristics. We used chi-square tests and logistic regressions to compare the availability of early pregnancy loss care based on institutional indication-based abortion restrictions and state legislative hostility to abortion care.

RESULTS

Of the 149 programs that responded (50.3% response rate), 74 (49.7%) reported that they did not offer any intervention for suspected early pregnancy loss unless rigid imaging criteria were met, whereas the remaining 75 (50.3%) programs reported that they incorporated imaging guidelines with other factors. In an unadjusted analysis, programs were less likely to incorporate other factors with imaging criteria if they were in a state with legislative policies that were hostile toward abortion (33% vs 79%; P<.001) or if the institution restricted abortion by indication (27% vs 88%; P<.001). Mifepristone was used less often in programs located in hostile states (32% vs 75%; P<.001) or in institutions with abortion restrictions (25% vs 86%; P<.001). Similarly, office-based suction aspiration use was lower in hostile states (48% vs 68%; P=.014) and in institutions with restrictions (40% vs 81%; P<.001). After controlling for program characteristics, including state policies and affiliation with family planning training programs or religious entities, institutional abortion restrictions were the only significant predictor of rigid reliance on imaging guidelines (odds ratio, 12.3; 95% confidence interval, 3.2-47.9).

CONCLUSION

In training institutions that restrict access to induced abortion based on indication for care, residency programs are less likely to holistically incorporate clinical evidence and patient priorities in determining when to intervene in early pregnancy loss as recommended by the American College of Obstetricians and Gynecologists. Programs in restrictive institutional and state environments are also less likely to offer the full range of early pregnancy loss treatment options. With state abortion bans proliferating nationwide, evidence-based education and patient-centered care for early pregnancy loss may also be hindered.

Effect of age on U.S. gynecologic patients' use of social media for women's health information

OBJECTIVE

To compare use, timing, and perceived benefit of social media for women's health information between different aged gynecologic patients.

METHODS

We performed a cross-sectional survey of patients presenting to a U.S. academic gynecology clinic over three months in spring 2021. We compared social media use for women's health information among patients of different age groups.

RESULTS

Most respondents use social media to learn about women's health (57.0 %), believe women's health information should be available on social media (92.4 %), and find it helpful in making health decisions (58.5 %), without significant differences by age group. With each increasing decade of age, patients increasingly reported actively searching for women's health information rather than passively finding it on a feed (p = 0.024 for overall comparison) and using social media for health information specifically around doctor's visits (p = 0.023 for overall comparison), and less commonly reported trusting social media influencers (p = 0.030 for overall comparison).

CONCLUSION

Reproductive and non-reproductive aged patients all highly utilize social media for women's health information, however there are differences in usage patterns by age.

PRACTICE IMPLICATIONS

Understanding social media use patterns can facilitate direction to and creation of accessible, medically-accurate and patient-friendly content.

Classification of periviable pregnancy-ending interventions for maternal life endangerment as induced abortion

OBJECTIVE

To explore how U.S. OB/GYNs classify periviable pregnancy-ending interventions for maternal life endangerment.

STUDY DESIGN

From May-July 2021, we performed an explanatory sequential mixed methods study of U.S. OB/GYNs, recruited through social media and professional listservs. We administered a cross-sectional survey requesting institutional classification of labor induction or surgical evacuation of a 22-week pregnancy affected by intrauterine infection, using chi-square tests and logistic regression to compare determinations by physician and institutional factors. We then conducted semi-structured interviews in a diverse nested sample to explore decision-making, merging quantitative and qualitative data in a mixed methods analysis.

RESULTS

We received 209 completed survey responses, with 101 (48.3%) current abortion providers and 48 (20.1%) never-providers, and completed 21 qualitative interviews. Fewer than half of respondents reported that pregnancy-ending intervention for 22-week intrauterine infection would be classified as induced abortion at their institution (induction: 21.1%, dilation & evacuation: 42.6%, p<0.001). In addition to procedure method, decision-making factors for classification as abortion included personal experience with abortion (with more experienced participants more likely to identify care as abortion) and state and institutional abortion regulations ("I have to call it a medical [induction]…I'm not allowed to use the word abortion").

CONCLUSIONS

Most OB/GYNs do not classify periviable pregnancy-ending interventions for life-threatening maternal complications as induced abortion, especially when physicians and institutions have less abortion expertise. Differential classification of pregnancy-ending care may lead to under-counting of later abortion procedures, masking the impact of abortion restrictions.

A mystery client study of crisis pregnancy center practices in New York State

OBJECTIVES

To evaluate practices of crisis pregnancy centers (CPCs) in a state with supportive abortion policies.

STUDY DESIGN

We called all New York State CPCs regarding their services using a "mystery client" protocol, utilizing checklists and thematic analysis.

RESULTS

Of 86 CPCs, 67 (78%) encouraged in-person appointments, offering free medical services and support. Twelve centers (14%) spontaneously disclosed their non-medical status, and 36 (42%) disclosed after direct questioning. Sixty-five (76%) made inaccurate or inflammatory statements about pregnancy or abortion.

CONCLUSIONS

In a state without specific barriers to abortion and pregnancy care, CPCs claim to provide support while using inflammatory rhetoric and concealing their organizational status.

Effect of a family planning program on documented emotional support and reproductive goals counseling after previable pregnancy loss

OBJECTIVES

To evaluate the effect of the Ryan Program for family planning training on patient counseling surrounding previable pregnancy loss.

METHODS

We conducted a retrospective cohort study of patients with first- and second-trimester miscarriages, therapeutic abortions, ectopic and molar pregnancies, from years before and after establishing a Ryan Program. We compared documentation of coping and future reproductive goals by patient factors, using chi square testing and logistic regression.

RESULTS

We included 285 pregnancies: 138 pre-Ryan, 147 post-Ryan. Documentation of coping and future goals was greater post-Ryan than pre-Ryan (57.8% vs. 26.8% for coping, 72.8% vs. 50.7% for goals; both p < 0.001). Coping was less likely to be documented for adolescents (aOR 0.02), patients of Asian race (aOR 0.08), those diagnosed in the emergency department (aOR 0.22), and those with ectopic or molar pregnancy (aOR 0.14) (all p < 0.005). Coping documentation increased with second-trimester loss (aOR 6.19) and outpatient follow-up (aOR 3.41) (all p < 0.005).

CONCLUSIONS

Establishment of a Ryan Program was associated with greater attention to patient coping and goals after previable pregnancy loss. Patients experiencing medically-dangerous pregnancy losses receive less attention to their coping.

PRACTICE IMPLICATIONS

Comprehensive family planning training and outpatient access may improve patient-centeredness of care for previable pregnancy loss.

Prevalence and predictors of mother-infant skin-to-skin contact at birth: findings from a U.S. tertiary medical center

BACKGROUND

Immediate skin-to-skin contact has well-established benefits for both mother and baby. However, its implementation varies widely, with limited data on predictors.

OBJECTIVE

This study aimed to investigate prevalence, duration, and maternal and newborn predictors of immediate skin-to-skin contact following vaginal deliveries.

STUDY DESIGN

We conducted a retrospective cohort study of vaginal deliveries from May to October 2019 at Albany Medical Center. We abstracted patient demographic and clinical predictor variables from medical records. The primary outcome was prevalence of skin-to-skin contact during the first hour of life, including any and that meeting the World Health Organization standard of care (defined as initiation within 5 minutes lasting for 60 minutes without separation). The secondary outcome was skin-to-skin contact duration in minutes during the first hour of life. Data were analyzed using multivariate logistic and linear regression models as appropriate.

RESULTS

Among 635 mother-infant dyads, the prevalence of any skin-to-skin contact was 74% and the prevalence of skin-to-skin contact meeting the World Health Organization standard of care was 43%. Maternal higher education increased odds of any skin-to-skin contact [adjusted odds ratio, 2.34; 95% confidence interval, 1.07, 5.13], while maternal delivery complications were associated with decreased odds [adjusted odds ratio, 0.39; 95% confidence interval, 0.17, 0.91]. Infants with 1-minute Apgar scores of 0-3 were four times less likely to receive any skin-to-skin contact compared with infants with scores of 7-10 [adjusted odds ratio, 0.26; 95% confidence interval, 0.09, 0.75]. Other neonatal factors that decreased odds of skin-to-skin contact were multiple gestation [adjusted odds ratio, 0.06; 95% confidence interval, 0.02, 0.19], preterm delivery [adjusted odds ratio, 0.39; 95% confidence interval, 0.19, 0.78], and neonatal intensive care unit admission [adjusted odds ratio, 0.13; 95% confidence interval, 0.06, 0.29]. All significant neonatal predictors also significantly decreased skin-to-skin contact duration in minutes.

CONCLUSION

The practice of immediate skin-to-skin contact after vaginal delivery did not meet the recommended standard. Neonatal complications and lower maternal educational level further reduced prevalence and duration, indicating the need for targeted educational interventions for patients and providers.

CONDENSATION

The prevalence and duration of immediate skin-to-skin contact after vaginal delivery are lower than recommended. Staff and patient education could mitigate some barriers.HighlightsSkin-to-skin contact occurs less often and with shorter duration than recommendedNewborn health is a stronger predictor of skin-to-skin contact than maternal healthHigher maternal education increases prevalence of skin-to-skin contact.

Individual abortion providers' experiences with targeted harassment in the United States

OBJECTIVE

To understand individual abortion providers' experiences with targeted harassment.

STUDY DESIGN

We conducted a cross-sectional survey of a convenience sample of US physicians with history of abortion provision, recruited through online groups, and listservs. Respondents completed a Qualtrics survey reporting personal and practice characteristics and experiences with harassment. We calculated descriptive statistics, comparing those who had and hadn't experienced targeted harassment using χ² tests, and we qualitatively analyzed free-text descriptions of harassment experiences to identify themes.

RESULTS

Of 321 respondents, 112 (35%) reported harassment. Targeted harassment was more likely with each decade of increasing age, and was greater for respondents providing outpatient versus only inpatient surgical abortion care (40% vs. 7%, p < 0.001) and care beyond the first trimester compared to only in the first trimester (39% vs. 16%, p = 0.001). Sixty-two respondents (19%) were not currently providing abortions, with 33 (52%) explicitly forbidden from doing so by their employers. Qualitative analysis revealed that most harassment is invasive and intimidating rather than overtly violent, with many providers experiencing intentional public exposure of their abortion work and having their professionalism discredited. Ensuing isolation of providers from their communities both perpetuates and facilitates further abortion provider stigma and harassment.

CONCLUSIONS

Targeted harassment toward abortion providers is widespread and attempts to intimidate providers and isolate them from their communities. More research is needed to explore ways to mitigate isolation of providers, which could improve safety, and have positive effects on the abortion workforce.

Effects of rotating at a Catholic hospital on medical student contraceptive objective structured clinical exam scores

OBJECTIVES

To assess the impact of rotating at a Catholic vs non-religious institution for the inpatient portion of the third-year medical school obstetrics and gynecology clerkship on medical students' contraceptive competency.

STUDY DESIGN

We assigned all medical students completing an obstetrics and gynecology clerkship during the 2017-2019 academic years to a Catholic or non-religious hospital for their inpatient teaching site, where they gain much of their contraceptive counseling experience. All students attended the same didactic sessions on contraception. We compared Objective Structured Clinical Exam (OSCE) scores and clerkship grades between the two clinical sites for all medical students. We set significance at p < 0.05.

RESULTS

Of 281 medical students, the 127 (45.2%) who had rotated at a Catholic hospital performed lower on the data-gathering component of the contraceptive OSCE compared with students at the non-religious hospitals (Catholic: 62.4 ± 16.5 vs non-religious: 70.2 ± 15.9, p < 0.01) and had lower total contraceptive OSCE scores (Catholic: 69.4 ± 9.3 vs non-religious: 72.0 ± 8.5, p < 0.01). Clinical reasoning and communication scores for the contraceptive OSCE, data-gathering and total scores for other OSCE scenarios, overall OSCE and clerkship grades were not different.

CONCLUSION

Rotation at a Catholic hospital, with fewer opportunities for medical students to experience contraceptive counseling, was associated with poorer data-gathering skills for gynecologic and sexual history. While contraceptive knowledge can be imparted didactically, hands-on history-taking and counseling experiences are needed to build competency in contraceptive care.

IMPLICATIONS

There is a disparity in medical student family planning training at a Catholic hospital compared with non-religious hospitals. Contraceptive knowledge can be attained through didactic sessions, however additional hands-on practice is needed in gynecologic and sexual history taking if clinical opportunities are limited.

A single-blinded randomized controlled trial evaluating pain and opioid use after dilator placement for second-trimester abortion

OBJECTIVES

To compare pain levels and medication needs after placement of laminaria vs Dilapan-S, and after dilation and evacuation (D&E).

STUDY DESIGN

We conducted a single-blinded randomized control trial of patients undergoing D&E at 15 0/7 to 23 6/7 weeks gestation, randomizing to cervical preparation with laminaria or Dilapan-S. We compared pain levels and medication usage following dilator placement (5 minutes; 2, 4, and 8 hours; the following morning) and D&E (1, 4, 24, and 48 hours). Our primary outcome was median change from baseline pain, and secondary outcomes included maximum pain timing and overall narcotic use. We compared baseline characteristics, median pain increases and quantities of narcotics used.

RESULTS

We analyzed 67 participants with laminaria (n = 34) and Dilapan-S (n = 33). More Dilapan-S users had a prior vaginal delivery (n = 20, 60.6%) than laminaria users (n = 11, 32.4%), p = 0.02. Maximum median pain was not statistically different (Laminaria: +3.5 (interquartile range [IQR] +0.5, +6.5); Dilapan-S: +3 (IQR +1, +5); p = 0.42. Thirty-seven (63.8%) participants reported higher levels of pain following dilator placement than D&E. Overall, 26 (42.6%) participants used narcotics during their abortion episode, with no difference in median number of tablets between laminaria (2, range 1-8) and Dilapan-S (4.5, range 1-15) participants (p = 0.34).

CONCLUSIONS

Median pain increase did not differ in participants receiving laminaria or Dilapan-S for cervical preparation prior to D&E. The majority of patients will use a small amount of narcotics if available.

IMPLICATIONS

The lack of difference in pain between laminaria and Dilapan-S enhances the applicability of pain intervention research across dilator types. With over half of participants using a small amount of narcotics during their D&E episode, pain management should be individualized to patient needs.

Exploring the Relationship between Abortion Provision and Providers' Personal Pregnancy and Parenting Experiences

OBJECTIVE

Support for abortion rights is often portrayed as antithetical to valuing family. With abortion provider demographics trending toward younger and female physicians, we sought to understand the influence of personal experiences with parenthood and pregnancy on abortion provision.

STUDY DESIGN

We surveyed U.S. physicians who have provided abortions, recruited from listservs and online groups. We calculated descriptive statistics using Stata SE. We used an inductive editing approach in coding free-text responses to questions about the emotional and experiential interplay between pregnancy, parenthood, and abortion provision, iteratively developing and refining a codebook, and ultimately identifying common themes.

RESULTS

We collected qualitative data from 227 participants, the majority of whom were under age 40 (51.1%), female (93.0%), and OB/GYN physicians (75.8%). Qualitative analysis yielded four main themes. 1) Providers feel dissonance between the societal expectation of conflict between abortion provision and parenthood and their lived experiences. 2) Abortion providers' personal experiences with pregnancy and parenthood increase compassion and stimulate a stronger therapeutic bond. 3) Pregnant abortion providers are sometimes affected by the contrast between ending one pregnancy while advancing another; however, most providers are able to contextualize their patients' need for abortion separately from their feelings about their own pregnancies and children. 4) Providers feel their abortion work positively impacts their parenting.

CONCLUSIONS

Our research demonstrates multiple effects of the interplay between abortion providers' personal reproductive experiences and their abortion provision, with a mutually positive overall relationship between parenting and abortion provision. Exploring this interaction could help to decrease stigma toward both abortion and abortion providers.

Examining intendedness among pregnancies ending in spontaneous abortion

OBJECTIVES

Spontaneous abortion (SAB) affects over 1 million US women each year, yet little is known about the intendedness of these pregnancies. We examined prevalence and correlates of unintended and unwanted pregnancies ending in SAB.

STUDY DESIGN

We used nationally-representative cross-sectional data of US women aged 15-44 from the 2011-2013 National Survey of Family Growth to examine pregnancies ending in SAB. We used modified Poisson regression models to evaluate associations between demographic and pregnancy characteristics with unintended and unwanted pregnancy.

RESULTS

Among 1351 pregnancies ending in SAB, 44.5% were unintended (i.e. unwanted or occurring sooner than desired). Younger women with SAB were more likely to report unintended pregnancies than women 30-44 years, and women 15-19 years reported unintended pregnancy most often [adjusted relative risk (aRR)=3.0; 95% confidence interval (CI): 2.2-4.1]. Unintended pregnancy was two times more likely among unmarried than married women [never married: aRR=2.2; 95% CI: 1.7-2.7; previously married: aRR=2.2; 95% CI: 1.7-3.0]. Other factors associated with unintended pregnancy were multiparity compared to nulliparity [aRR=2.6; 95% CI: 1.7-4.1 for ≥3 children; aRR=1.8; 95% CI: 1.3-2.5 for 2 children] and inter-pregnancy interval ≤12 months compared to >12 months [aRR=1.4; 95% CI: 1.2-1.7]. We found similar associations with unwanted pregnancies ending in SAB (15.3% of pregnancies). Neither race/ethnicity nor socioeconomic indicators were independently associated with unintended or unwanted pregnancy ending in SAB.

CONCLUSIONS

Many pregnancies ending in spontaneous abortion are unintended and/or unwanted. Women with pregnancy loss, like all reproductive-aged women, should receive comprehensive counseling about reproductive planning and contraception.

IMPLICATIONS

Similar to all pregnancies, nearly half of pregnancies ending in spontaneous abortion are unintended and/or unwanted, suggesting that many women experiencing spontaneous abortion may benefit from a review of family planning desires and the provision of reproductive planning counseling and effective contraception to prevent future undesired pregnancy.