Meeting Preferences for Specific Contraceptive Methods: An Overdue Indicator

Fertility surveys have rarely asked people who are using contraception about the contraceptive method they would like to be using, implicitly assuming that those who are contracepting are using the method they want. In this commentary, we review evidence from a small but growing body of work that oftentimes indicates this assumption is untrue. Discordant contraceptive preferences and use are relatively common, and unsatisfied preferences are associated with higher rates of method discontinuation and subsequent pregnancy. We argue that there is opportunity to center autonomy and illuminate the need for and quality of services by building on this research and investing in the development of survey items that assess which method people would like to use, as well as their reasons for nonpreferred use. The widespread adoption of questions regarding method preferences could bring indicators of reproductive health services into closer alignment with the needs of the people they serve.

Service delivery at Title X sites in Texas during the COVID-19 pandemic

CONTEXT

The important role of Title X sites in supporting publicly funded reproductive healthcare was elevated during the COVID-19 pandemic, as many people experienced economic uncertainty and changed their fertility preferences. In this study, we assessed changes in service delivery during the first year of the COVID-19 pandemic at Title X-supported sites in Texas, a large state with a high uninsured rate and a diverse Title X network.

METHODS

Using surveys of Title X-funded organizations in Texas from April and November 2020, we examined the percentage of organizations reporting service modifications. With administrative data on 507,947 client encounters between March 2019 and March 2021, we assessed change in client volume at the onset of the pandemic and evaluated the association between regional COVID-19 case rates and the provision of key Title X services.

RESULTS

In April 2020, most organizations (78%) limited in-person operations while implementing telehealth (74%) and contactless contraception (67%). Network-wide encounter volume declined by 26% at pandemic onset (incidence rate ratio [IRR] = 0.74, 95% confidence interval [CI] = 0.65, 0.84). Health departments experienced the steepest declines in encounter volume (IRR = 0.43, 95% CI = 0.36-0.50). Weekly encounters, particularly for long-acting reversible method placement/removal and sexually transmitted infection testing, decreased as COVID-19 rates increased.

CONCLUSIONS

Investment in public health infrastructure, including providing robust support to health departments as well as rebuilding and expanding the Title X network, is essential to safeguarding access to publicly funded reproductive healthcare during and after the pandemic.

Does the Impact of Motherhood on Women's Employment and Wages Differ for Women Who Plan Their Transition Into Motherhood?

Women's ability to control their fertility through contraception and abortion has been shown to contribute to improvements in education and employment. At the same time, their employment and wages decline substantially when they transition to motherhood. About one-third of births are unintended, and it is unknown whether the impact of motherhood on employment, hours, and wages is smaller for women who planned their transition into motherhood compared with those who did not. To explore this, we examine fixed-effects models that estimate labor market outcomes using panel data from the National Longitudinal Survey of Youth, 1979-2014. We estimate models for Black and White women and find that the relationship between motherhood and employment is significantly more negative among White women who plan their transition into motherhood than among those who have an unplanned first birth. Among those who remain employed, we find that those with a planned first birth work fewer hours and have lower wages relative to those with unplanned births. We do not find significant evidence that the association between motherhood and labor market outcomes differs by fertility planning among Black women. Prior research shows how women's choices are structurally constrained by sociocultural norms and expectations and by a labor market that may not readily accommodate motherhood. In this context, our findings may reflect differences in women's motherhood and employment preferences and their ability to act on those preferences. Our analysis also makes a novel contribution to the large body of research that associates unplanned births with negative outcomes.

Short-acting hormonal contraceptive continuation among low-income postpartum women in Texas

OBJECTIVE

The objective was to assess continuation of the pill, patch, ring or injectable (i.e., short-acting hormonal contraception); characteristics associated with discontinuation; and subsequent method use among low-income postpartum women in Texas.

STUDY DESIGN

Using a 24-month cohort study of 1700 women who delivered in eight Texas hospitals and were uninsured or publicly insured at the time of delivery, we focused on 456 women who used short-acting hormonal contraception within 6 months after delivery. We classified this sample according to characteristics and method preference, and estimated rates of discontinuation and associated predictors using life tables and Cox models. We assessed reasons for discontinuation and subsequent contraceptive use among those who discontinued.

RESULTS

Roughly half used the pill and half used the injectable. One hundred seventy-eight (39%) expressed a baseline preference for the method they used, 162 (36%) preferred a long-acting reversible contraception method, and 41 (9%) preferred sterilization. After 1 year, 72% had discontinued [95% confidence interval (CI) 67.1-75.7]. Foreign-born Hispanic women were less likely to discontinue than U.S.-born Hispanics [adjusted hazard ratio (aHR), 0.65; 95% CI 0.50-0.84]. Those who wanted a more effective method (aHR, 1.44; 95% CI 1.12-1.85) and those who lost insurance coverage (aHR, 1.47; 95% CI 1.12-1.92) were more likely to discontinue. The most common reasons for discontinuation were side effects and access/cost. Of those who discontinued, 243 (68%) switched to a less effective or no method. Only 47 (13%) switched to their preferred method.

CONCLUSIONS

Short-acting hormonal contraceptive discontinuation is high in this population. Many switch to less effective methods after discontinuation despite preferring methods at least as effective as the pill, patch, ring or injectable.

IMPLICATIONS

Expanding contraceptive coverage in the 2 years after delivery should be a state and federal policy priority. In clinics, providers should discuss contraceptive preferences throughout pregnancy and the interpregnancy interval.

Disparities and change over time in distance women would need to travel to have an abortion in the USA: a spatial analysis

Background

Abortion can help women to control their fertility and is an important component of health care for women. Although women in the USA who live further from an abortion clinic are less likely to obtain an abortion than women who live closer to an abortion clinic, no national study has examined inequality in access to abortion and whether inequality has increased as the number of abortion clinics has declined.

Methods

For this analysis, we obtained data on abortion clinics for 2000, 2011, and 2014 from the Guttmacher Institute’s Abortion Provider Census. Block groups and the percentage of women aged 15–44 years by census tract were obtained from the US Census Bureau. Distance to the nearest clinic was calculated for the population-weighted centroid of every block group. We calculated the median distance to an abortion clinic for women in each county and the median and 80th percentile distances for each state by weighting block groups by the number of women of reproductive age (15–44 years).

Findings

In 2014, women in the USA would have had to travel a median distance of 10·79 miles (17·36 km) to reach the nearest abortion clinic, although 20% of women would have had to travel 42·54 miles (68·46 km) or more. We found substantially greater variation within than between states because, even in mostly rural states, women and clinics were concentrated in urban areas. We identified spatial disparities in abortion access, which were broadly unchanged, at least as far back as 2000.

Interpretation

We showed substantial and persistent spatial disparities in access to abortion in the USA. These results contribute to an emerging literature documenting similar disparities in other high-income countries.

Funding

An anonymous grant to the Guttmacher Institute.

Chimeric polioviruses that include sequences derived from two independent antigenic sites of foot-and-mouth disease virus (FMDV) induce neutralizing antibodies against FMDV in guinea pigs

Five poliovirus recombinants containing sequences corresponding to foot-and-mouth disease virus (FMDV) antigenic sites were constructed. Viable virus was recovered from four of these plasmids, in which the VP1 beta B-beta C loop (antigenic site 1) of poliovirus type 1 Sabin had been replaced with sequences derived from the VP1 beta G-beta H loop (antigenic site 1) of FMDV O1 Kaufbeuren (O1K), chimera O1.1 (residues 141 to 154), chimera O1.2 (residues 147 to 156), and chimera O1.3 (residues 140 to 160) or from the beta B-beta C loop of VP1 (antigenic site 3) in chimera O3.1 (residues 40 to 49). One chimera (O1.3) was neutralized by FMDV-specific polyclonal serum and monoclonal antibodies directed against antigenic site 1 of FMDV. Chimeras O1.3 and O3.1 induced site-specific FMDV-neutralizing antibodies in guinea pigs. Chimera O1.3 was capable of inducing a protective response against FMDV challenge in some guinea pigs.

An antigen chimera of poliovirus induces antibodies against human papillomavirus type 16

It has been established that the surface of poliovirus type 1 can be extensively modified to incorporate antigenic domains from other poliovirus serotypes and from unrelated viruses. The fact that the modified (chimeric) viruses exhibit dual antigenicity and immunogenicity led us to explore the possibility of using the Sabin vaccine strain of poliovirus type 1 as a vector for the presentation of antigenic domains from human papillomavirus type 16 (HPV-16), a virus associated with the development of cervical carcinoma. We report here the construction and characterization of a chimeric poliovirus containing a 16-residue sequence derived from the major capsid protein (L1) of HPV-16. This virus chimera stimulated the production in rabbits of antibodies which recognized the HPV-16-derived peptide and an L1 fusion protein synthesized in Escherichia coli and detected HPV-16 in human biopsy material by immunoperoxidase staining. The possibility that poliovirus-HPV chimeras could be used as vaccines against HPV-16 is discussed.

A cassette vector for the construction of antigen chimaeras of poliovirus

A cassette vector has been constructed which allows the rapid and extensive modification of one of the neutralizing antigenic sites of the Sabin 1 poliovirus vaccine strain, P1/LSc 2ab. Unique restriction endonuclease sites flanking antigenic site 1 have been engineered into a full-length infectious Sabin 1 cDNA clone with minimal alteration to the coding sequence. This facilitates replacement of this region by oligonucleotides encoding foreign amino acid sequences. Our results indicate that this region is highly flexible in terms of the number and sequence of amino acids which can be accommodated.

An engineered poliovirus chimaera elicits broadly reactive HIV-1 neutralizing antibodies

The Sabin type 1 vaccine strain of poliovirus is probably the safest and most successful live-attenuated vaccine virus used in humans. Its widespread use since the early 1960s has contributed significantly to the virtual eradication of poliomyelitis in developed countries. We have reported previously the construction of an intertypic antigen chimaera of poliovirus, based on the Sabin 1 strain, and proposed that this virus could be modified to express on its surface antigenic determinants from other pathogens. We describe here the construction and characterization of a poliovirus antigen chimaera containing an epitope from the transmembrane glycoprotein (gp41) of human immunodeficiency virus type 1 (HIV-1). In antibody absorption experiments, the virus chimaera inhibited neutralization of HIV-1 by antipeptide monoclonal antibodies specific for the gp41 epitope and significantly reduced the group specific neutralizing activity of HIV-1-positive human sera. Rabbit antisera raised by subcutaneous injection of the polio/HIV chimaera in adjuvant was shown to be specific for HIV-1 gp41 in peptide-binding assays and by western blotting. Moreover, the antisera neutralized a wide range of American and African HIV-1 isolates and also inhibited virus-induced cell fusion. Monoclonal antibodies against the HIV-1 derived regions of the chimaera also neutralized HIV-1. These results establish the potential of using poliovirus for the presentation of foreign antigens and suggest that Sabin 1 poliovirus/HIV chimaeras could offer an approach to the development of an HIV vaccine.

Antigen chimaeras of poliovirus as potential new vaccines

Polioviruses occur as three distinct serotypes, 1, 2 and 3, and are composed of a single-stranded positive-sense RNA genome of approximately 7,450 nucleotides enclosed in an icosahedral particle of diameter 27 nm. The three-dimensional crystallographic structure of poliovirus type 1 has been determined at 2.9 A resolution, providing a detailed knowledge of the folding and arrangement of the individual virus proteins, VP1-VP4. From this and the characterization of monoclonal antibody-resistant mutants, the amino acids contributing to antigenic sites have been identified and located on the surface of the virus particle. Here we describe the construction and characterization of a poliovirus chimaera having a defined region of type 3 inserted into type 1. This virus has composite antigenicity and the substitute site is immunogenic in small animals and primates. The ability to construct such viruses has implications for the design of improved poliovirus vaccine strains or vaccines against other picornaviruses, such as hepatitis A.