Assessing Contraceptive Switching and Discontinuation Over 3 Years in the HER Salt Lake Study

OBJECTIVE

To assess contraceptive switching and discontinuation among participants enrolled in a contraceptive access project over 3 years and to identify variables associated with contraceptive change.

METHODS

The HER Salt Lake study enrolled individuals between 2015 and 2017 from four clinics in Salt Lake County into a prospective, longitudinal cohort. All participants were able to switch or discontinue at no cost (between March 2016 and March 2020). We collected eight follow-up surveys over 3 years after enrollment. Each survey wave included questions about method use in the previous 4 weeks. We categorized participants in three ways, allowing for time-varying outcomes by wave: 1) those who reported using the same method as previous wave (continuers), 2) those who reported using a different method from previous wave (switchers), and 3) those who reported using no contraceptive method at that wave (discontinuers). We report the frequency of outcomes and conducted multinomial regression models assessing predictors of switching and discontinuation.

RESULTS

Among 4,289 participants included in this analysis, 2,179 (50.8%) reported at least one instance of switching or discontinuation, and 2,110 (49.1%) reported continuing with their baseline method at the end of the study. Those reporting method change (switching or discontinuing) reported an average of 1.93 change events over the study follow-up period (range 1-8). Among those reporting any method change, 522 participants (23.9%) reporting at least one instance of both switching and discontinuation. Among those reporting any instance of discontinuation (n=966), 498 (51.6%) never reported uptake of a subsequent method. Among those who did report a subsequent method (n=468), 210 (44.8%) reported restarting a previously used method, and 258 (55.1%) reported starting a new method. Although we identified overlap among variables associated with switching and discontinuation, other predictors were discordant between switching and discontinuation.

CONCLUSION

New contraceptive users commonly switch and discontinue methods. User behavior is associated with certain demographic characteristics and pregnancy planning.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT02734199.

Measuring a Critical Component of Contraceptive Decision Making: The Contraceptive Concerns and Beliefs Scale

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.

Patient experiences using public and private insurance coverage for abortion in Illinois: Implementation successes and remaining gaps

CONTEXT

Insurance coverage for abortion in states where care remains legal can alleviate financial burdens for patients and increase access. Recent policy changes in Illinois required Medicaid and some private insurance plans to cover abortion care. This study explores policy implementation from the perspectives of patients using their insurance to obtain early abortion care.

METHODOLOGY

Between July 2021 and February 2022, we interviewed Illinois residents who recently sought abortion care at ≤11 weeks of pregnancy. We also interviewed nine key informants with experience providing or billing for abortion or supporting insurance policy implementation in Illinois. We coded interview transcripts in Dedoose and developed code summaries to identify salient themes across interviews.

RESULTS

Most participants insured by Illinois Medicaid or eligible for enrollment received full coverage for their abortions; most with private insurance did not and faced challenges learning about coverage status. Some opted not to use insurance, often citing privacy concerns. Participants who benefited from abortion coverage expressed relief, gave examples of other financial challenges they could prioritize, and described feeling in control of their abortion experience. Those without coverage described feeling stressed, uncertain, and constrained in their decision-making.

CONCLUSION

When abortion was fully covered by insurance, it reduced financial burdens and enhanced reproductive autonomy. Illinois Medicaid policy-with seamless enrollment options and appropriate reimbursement rates-offers a model for improving abortion access in other states. Further investigation is needed to determine compliance among private insurance companies and increase transparency.

Navigating a climate of administrative burden: the perspectives of young adult undocumented immigrants in applying for COVID-19 disaster relief assistance for immigrants in California

Undocumented immigrants experienced high levels of economic insecurity during the COVID-19 pandemic while being excluded from government-based relief and unemployment benefits. In April 2020, California became the first state to offer financial aid to undocumented immigrants through the innovative Disaster Relief Assistance for Immigrants (DRAI) program in collaboration with several community-based organizations (CBOs). However, the process of applying for aid was marked by many implementation challenges, such as intake and language access; however, little data exists on the direct experiences of the undocumented community. This qualitative study examines the experiences of undocumented Asian and Latinx young adults living in California in applying for DRAI through framework of administrative burden. Themes distilled from participant experiences highlight how administrative burden via learning, psychological, and compliance costs shape the ways in which undocumented immigrants navigate policies and programs, such as DRAI. These experiences highlight the need for policymakers to address structural and programmatic administrative burdens in policy development; failure to do so result in detrimental impacts that outweigh financial benefits or cause communities to forgo needed resources.

Improving Reproductive Health Communication Between Providers and Women Affected by Homelessness and Substance Use in San Francisco: Results from a Community-Informed Workshop

OBJECTIVES

Many cisgender women affected by homelessness and substance use desire pregnancy and parenthood. Provider discomfort with patient-centered counseling about reproductive choices and supporting reproductive decisions of these women poses barriers to reproductive healthcare access.

METHODS

We used participatory research methods to develop a half-day workshop for San Francisco-based medical and social service providers to improve reproductive counseling of women experiencing homelessness and/or who use substances. Guided by a stakeholder group comprising cisgender women with lived experience and providers, goals of the workshop included increasing provider empathy, advancing patient-centered reproductive health communication, and eliminating extraneous questions in care settings that perpetuate stigma. We used pre/post surveys to evaluate acceptability and effects of the workshop on participants' attitudes and confidence in providing reproductive health counseling. We repeated surveys one month post-event to investigate lasting effects.

RESULTS

Forty-two San Francisco-based medical and social service providers participated in the workshop. Compared to pre-test, post-test scores indicated reduced biases about: childbearing among unhoused women (p < 0.01), parenting intentions of pregnant women using substances (p = 0.03), and women not using contraception while using substances (p < 0.01). Participants also expressed increased confidence in how and when to discuss reproductive aspirations (p < 0.01) with clients. At one month, 90% of respondents reported the workshop was somewhat or very beneficial to their work, and 65% reported increased awareness of personal biases when working with this patient population.

CONCLUSIONS FOR PRACTICE

A half-day workshop increased provider empathy and improved provider confidence in reproductive health counseling of women affected by homelessness and substance use.

A qualitative analysis of pharmacists' attitudes towards provision of medication abortion

BACKGROUND

90% of United States' counties do not have a single clinic offering abortion care, and barriers to care disproportionately affect low-income families. Novel models of abortion care delivery, including provision of medication abortion in pharmacies, with pharmacists prescribing medication, have the potential to expand access to abortion care. Pharmacists are well-positioned to independently provide abortion care and are highly accessible to patients, however medication abortion provision by pharmacists is not currently legal or available in the United States. To assess the potential acceptability of pharmacist provision of medication abortion and to identify anticipated barriers and facilitators to this model of care, we explored pharmacists' attitudes towards providing medication abortion, inclusive of patient selection, counseling, and medication prescribing.

METHODS

From May to October 2021, we conducted 20 semi-structured qualitative interviews with pharmacists across the United States, guided by the domains of the Consolidated Framework for Implementation Science Research.

RESULTS

Major themes included there is a need for pharmacist provision of medication abortion and pharmacists perceive provision of medication abortion to be potentially acceptable if anticipated barriers are addressed. Anticipated barriers identified included personal, religious, and political beliefs of pharmacists and lack of space and systems to support the model. Ensuring adequate staffing with pharmacists willing to participate, private space, time for counseling, safe follow-up, training, and reimbursement mechanisms were perceived strategies to facilitate successful implementation.

CONCLUSIONS

Pharmacist identified implementation strategies are needed to reduce anticipated barriers to pharmacist provision of medication abortion.

Runx2 overexpression promotes bone repair of osteonecrosis of the femoral head (ONFH)

BACKGROUND

Runt-related transcription factor-2 (Runx2) has been considered an inducer to improve bone repair ability of mesenchymal stem cells (MSCs).

METHODS AND RESULTS

Twenty-four rabbits were used to establish Osteonecrosis of the femoral head (ONFH) and randomly devided into four groups: Adenovirus Runx2 (Ad-Runx2) group, Runx2-siRNA group, MSCs group and Model group. At 1 week after model establishment, the Ad-Runx2 group was treated with 5 × 107 MSCs transfected through Ad-Runx2, the Runx2-siRNA group was treated with 5 × 107 MSCs transfected through Runx2-siRNA, the MSCs group was injected with 5 × 107 untreated MSCs, and the Model group was treated with saline. The injection was administered at 1 week and 3 weeks after model establishment. The expression of bone morphogenetic protein 2 (BMP-2), Runx2 and Osterix from the femoral head was detected at 3 and 6 weeks after MSCs being injected, and Masson Trichrome Staining, Gross Morphology, X-ray and CT images observation were used to evaluate the repair effect of ONFH. The data revealed that the expression of BMP-2, Runx2 and Osterix in the Runx2-siRNA group was reduced at 3 weeks compared with the MSCs group, and then the expression further reduced at 6 weeks, but was still higher than the Model group besides Osterix; The expression of these three genes in the Ad-Runx2 group was higher than in the MSCs group. Masson Trichrome Staining, Gross Morphology and X-ray and CT images observation revealed that necrotic femoral head of the MSCs group was more regular and smooth than the Runx2-siRNA group, which has a collapsed and irregular femoral head. In the Ad-Runx2 group, necrotic femoral head was basically completely repaired and covered by rich cartilage and bone tissue.

CONCLUSIONS

Overexpression of Runx2 can improve osteoblastic phenotype maintenance of MSCs and promote necrotic bone repair of ONFH.

Health care provider bias in the Appalachian region: The frequency and impact of contraceptive coercion

OBJECTIVE

To investigate the frequency and impact of contraceptive coercion in the Appalachian region of the United States.

DATA SOURCES AND STUDY SETTING

In fall 2019, we collected primary survey data with participants in the Appalachian region.

STUDY DESIGN

We conducted an online survey including patient-centered measures of contraceptive care and behavior.

DATA COLLECTION/EXTRACTION METHODS

We used social media advertisements to recruit Appalachians of reproductive age who were assigned female at birth (N = 622). After exploring the frequency of upward coercion (pressure to use contraception) and downward coercion (pressure not to use contraception), we ran chi-square and logistic regression analyses to explore the relationships between contraceptive coercion and preferred contraceptive use.

PRINCIPAL FINDINGS

Approximately one in four (23%, n = 143) participants reported that they were not using their preferred contraceptive method. More than one-third of participants (37.0%, n = 230) reported ever experiencing coercion in their contraceptive care, with 15.8% reporting downward coercion and 29.6% reporting upward coercion. Chi-square tests indicated that downward (χ² (1) = 23.337, p < 0.001) and upward coercion (χ² (1) = 24.481, p < 0.001) were both associated with a decreased likelihood of using the preferred contraceptive method. These relationships remained significant when controlling for sociodemographic factors in a logistic regression model (downward coercion: Marginal effect = -0.169, p = 0.001; upward coercion: Marginal effect = -0.121, p = 0.002).

CONCLUSIONS

This study utilized novel person-centered measures to investigate contraceptive coercion in the Appalachian region. Findings highlight the negative impact of contraceptive coercion on patients' reproductive autonomy. Promoting contraceptive access, in Appalachia and beyond, requires comprehensive and unbiased contraceptive care.

Computed tomography texture analysis combined with preoperative clinical factors serve as a predictor of early efficacy of transcatheter arterial chemoembolization in hepatocellular carcinoma

AIM

To investigate a pre-therapeutic radiomics nomogram to accurately predict hepatocellular carcinoma (HCC) lesion responses to transcatheter arterial chemoembolization (TACE).

METHODS

This retrospective study from January 2012 to 2022 included 92 TACE-treated patients who underwent liver contrast-enhanced CT scan 7 days before treatment, having complete clinical information. We extracted quantitative texture parameters and clinical factors for the largest tumors on the baseline arterial and portal venous phase CT images. An adaptive least absolute shrinkage and selection operator (LASSO)-penalized logistic regression identified independent predictors of tumor activity after TACE.

RESULTS

We fitted an adaptive LASSO regression model to narrow down the texture features and clinical risk factors of the tumor activity status. The selected texture features were used to construct radiomic scores (RadScore), which demonstrated superior performance in predicting tumor activity on both the training (area under the curve (AUC): 0.881, 95% CI: 0.799-0.963) and testing sets (AUC: 0.88, 95% CI: 0.726-1). A logistic regression-based nomogram was developed using RadScore and four selected clinical features. In the testing set, nomogram total points were significant predictors (P = 0.034), and the training set showed no departure from perfect fit (P = 0.833). Internal validation of the nomogram was obtained for the training (AUC: 0.91, 95% CI: 0.837-0.984) and testing (AUC: 0.889, 95% CI: 0.746-1) sets.

CONCLUSION

We propose a nomogram to predict the early response of HCC lesions to TACE treatment with high accuracy, which may serve as an additional criterion in multidisciplinary decision-making treatment.

Measuring Contraceptive Autonomy at Two Sites in Burkina Faso: A First Attempt to Measure a Novel Family Planning Indicator

There is growing consensus in the family planning community around the need for novel measures of autonomy. Existing literature highlights the tension between efforts to pursue contraceptive targets and maximize uptake on the one hand, and efforts to promote quality, person-centeredness, and contraceptive autonomy on the other hand. Here, we pilot a novel measure of contraceptive autonomy, measuring it at two Health and Demographic Surveillance System sites in Burkina Faso. We conducted a population-based survey with 3,929 women of reproductive age, testing an array of new survey items within the three subdomains of informed choice, full choice, and free choice. In addition to providing tentative estimates of the prevalence of contraceptive autonomy and its subdomains in our sample of Burkinabè women, we critically examine which parts of the proposed methodology worked well, what challenges/limitations we encountered, and what next steps might be for refining, improving, and validating the indicator. We demonstrate that contraceptive autonomy can be measured at the population level but a number of complex measurement challenges remain. Rather than a final validated tool, we consider this a step on a long road toward a more person-centered measurement agenda for the global family planning community.

Structured Engagement of Community Partners to Revise a Pregnancy Options Counseling Curriculum for Pediatric Residents

OBJECTIVE

The engagement of community partners, including patients, is increasingly recognized as important in developing medical education curricula. Structured methodology for partner engagement in curriculum development is lacking in the existing literature. This article describes a structured approach to engaging community partners to provide input on revising a curriculum for pediatric residents about pregnancy options counseling with adolescents.

METHODS

We used the five-step Method for Program Adaptation through Community Engagement: (1) development of a panel of community partners including patients and professionals, (2) and (3) partner evaluation of the existing curriculum and recommendations for revisions, (4) summarization of partner feedback, and (5) development of the revised curriculum. We surveyed partners about their perceived impact on the revision and satisfaction with the process.

RESULTS

Seventeen partners participated. Five experienced adolescent pregnancy, while the remaining 12 included healthcare and social service professionals. All partners provided multiple recommendations, generating 124 discrete recommendations. Twenty recommendations were suggested by multiple individuals. The authors reviewed all recommendations by category during consensus meetings and determined which recommendations would be incorporated into the revised curriculum to meet stated learning objectives. We implemented 14 of these 20 recommendations, including adding a values clarification exercise, information about mental health crisis resources, and more detail about adoption. We also incorporated 15 individual recommendations pertaining to curriculum clarity. Recommendations from professionals and patients were similar. Fourteen out of 17 participants completed the survey at the close of the project. All respondents understood their roles, were satisfied with their degree of engagement, and felt that their expectations for participation were met or exceeded.

CONCLUSIONS

This study describes a methodology for a formal process to engage community partners in curriculum development and revision processes. Such methodology can ensure that medical education curricula are optimally attuned to the needs of key community members and integrate the patient's voice.

"It just seemed like a perfect storm": A multi-methods feasibility study on the use of Facebook, Google Ads, and Reddit to collect data on abortion-seeking experiences from people who considered but did not obtain abortion care in the United States

Most studies of abortion access have recruited participants from abortion clinics, thereby missing people for whom barriers to care were insurmountable. Consequently, research may underestimate the nature and scope of barriers that exist. We aimed to recruit participants who had considered, but failed to obtain, an abortion using three online platforms, and to evaluate the feasibility of collecting data on their abortion-seeking experiences in a multi-modal online study. In 2018, we recruited participants for this feasibility study from Facebook, Google Ads, and Reddit for an online survey about experiences seeking abortion care in the United States; we additionally conducted in-depth interviews among a subset of survey participants. We completed descriptive analyses of survey data, and thematic analyses of interview data. Recruitment results have been previously published. For the primary outcomes of this analysis, over one month, we succeeded in capturing data on abortion-seeking experiences from 66 individuals who were not currently pregnant and reported not having obtained an abortion, nor visited an abortion facility, despite feeling that abortion could have been the best option for a recent pregnancy. A subset of survey respondents (n = 14) completed in-depth interviews. Results highlighted multiple, reinforcing barriers to abortion care, including legal restrictions such as gestational limits and waiting periods that exacerbated financial and other burdens, logistical and informational barriers, as well as barriers to abortion care less frequently reported in the literature, such as a preference for medication abortion. These findings support the use of online recruitment to identify and survey an understudied population about their abortion-seeking experiences. Further, findings contribute to a more complete understanding of the full range of barriers to abortion care that people experience in the United States, and how these barriers intersect to not just delay, but to prevent people from obtaining abortion.

U.S. Abortion Care Providers' Perspectives on Self-Managed Abortion

State-level restrictions on abortion access may prompt greater numbers of people to self-manage their abortion. The few studies exploring perspectives of providers towards self-managed abortion are focused on physicians and advanced practice clinicians. Little is known about the wider spectrum of abortion care providers who encounter self-managed abortion in their clinic-based work. To gain a deeper understanding of this issue and inform future care delivery, we conducted in-depth interviews with 46 individuals working in a range of positions in 46 abortion clinics across 29 states. Our interpretative analysis resulted in themes shaped by beliefs about safety and autonomy, and a tension between the two: that self-managed abortion is too great a risk, that people are capable of self-managing an abortion, and that people have a right to a self-managed abortion. Our findings highlight the importance of increasing knowledge and clarifying values among all abortion care providers, including clinic staff.

Introducing the Dilation and Evacuation Technique in Brazil: Lessons Learned From an International Partnership to Expand Options for Brazilian Women and Girls

Dilation and evacuation (D&amp;E) is the recommended surgical procedure for uterine evacuation in the second trimester. Despite its established safety record, it is not routinely available in most countries around the world. In this paper, we describe the multi-phase capacity-building project we undertook to introduce D&amp;E in Brazil. First, we invited a highly motivated obstetrician-gynecologist and abortion provider to complete an observership at an established D&amp;E site in the United States. We then organized a month-long clinical training for two experienced gynecologists in Brazil, followed by ongoing remote mentorship. Almost all patients we approached during the training opted for D&amp;E, and all expressed satisfaction with their experience. Despite the restrictive legal setting and prevailing abortion stigma in Brazil, our training was well-received, and we did not experience any overt resistance from hospital staff. We learned that obtaining institutional support is essential; and that presenting scientific evidence during dedicated didactic times was an important strategy to obtain buy-in from other local healthcare providers. An important challenge we encountered was low case volume given the restrictive legal setting. We addressed this by partnering with nearby hospitals and non-profit organizations for patient referrals. We also rescheduled, adapted and optimized this project for implementation in the midst of the COVID-19 pandemic. Despite the challenges we faced, this project led to the successful introduction of D&amp;E up to 16–18 weeks at two sites in Brazil. In the future, we plan additional training to increase capacity for D&amp;E at more advanced gestational ages.

Abortion attempts without clinical supervision among transgender, nonbinary and gender-expansive people in the United States

BACKGROUND

Transgender, nonbinary and gender-expansive (TGE) people face barriers to abortion care and may consider abortion without clinical supervision.

METHODS

In 2019, we recruited participants for an online survey about sexual and reproductive health. Eligible participants were TGE people assigned female or intersex at birth, 18 years and older, from across the United States, and recruited through The PRIDE Study or via online and in-person postings.

RESULTS

Of 1694 TGE participants, 76 people (36% of those ever pregnant) reported considering trying to end a pregnancy on their own without clinical supervision, and a subset of these (n=40; 19% of those ever pregnant) reported attempting to do so. Methods fell into four broad categories: herbs (n=15, 38%), physical trauma (n=10, 25%), vitamin C (n=8, 20%) and substance use (n=7, 18%). Reasons given for abortion without clinical supervision ranged from perceived efficiency and desire for privacy, to structural issues including a lack of health insurance coverage, legal restrictions, denials of or mistreatment within clinical care, and cost.

CONCLUSIONS

These data highlight a high proportion of sampled TGE people who have attempted abortion without clinical supervision. This could reflect formidable barriers to facility-based abortion care as well as a strong desire for privacy and autonomy in the abortion process. Efforts are needed to connect TGE people with information on safe and effective methods of self-managed abortion and to dismantle barriers to clinical abortion care so that TGE people may freely choose a safe, effective abortion in either setting.

Preventing first births among adolescents in Mexico City's public abortion programme

INTRODUCTION

We examined parity and age among women seeking an abortion in Mexico City's public first-trimester abortion programme, Interrupcion Legal de Embarazo (ILE). We hypothesised that younger women, especially students, used abortion to prevent first births while older women used abortion to limit births.

METHODS

We used clinical data from a sample of 47 462 women who had an abortion between 2007 and 2016 and classified them as nulliparous or parous according to previous births prior to the abortion. We used logistic regression to identify sociodemographic and clinical factors associated with using abortion to prevent a first birth (nulliparous) versus limiting births (parous) and calculated absolute multivariable predicted probabilities.

RESULTS

Overall, 41% of abortions were in nulliparous women seeking to prevent a first birth, and 59% were in women who already had one or more children. The adjusted probability of using abortion to prevent a first birth was 80.4% (95% CI 78.3 to 82.4) for women aged 12-17 years and 54.3% (95% CI 51.6 to 57.0) for women aged 18-24 years. Adolescents (aged 12-17 years) who were employed or students had nearly 90% adjusted probability of using abortion to prevent a first birth (employed 87.8%, 95% CI 82.9 to 92.8; students 88.5%, 95% CI 82.9 to 94.1). At all ages, employed women and students had higher probabilities of using abortion to prevent a first birth compared with unemployed women and women who work in the home.

CONCLUSION

Legal first-trimester abortion services in Mexico can help prevent first births in adolescents, especially students.

Factors Associated with Support for Adolescent Access to Contraception Among Mexican Catholic Parents

We used a nationally representative survey of 2186 Mexican Catholic parents to assess two outcomes: support for adolescent access to modern contraception and whether adolescents unaccompanied by an adult should have access to contraceptive methods. A majority (85%) of Mexican Catholic parents support adolescent access to modern contraceptive methods, but there was less support (28%) for access to contraception unaccompanied. Further, our results show strong support (92%) for sex education in schools. Parents who believe that good Catholics can use contraception had higher odds of support for adolescent access and unaccompanied access to modern contraception. Mexican Catholic parents support adolescent access to modern contraception, but support for unaccompanied access to contraception is lower. This may reflect an interest in being involved, and not necessarily opposition to contraceptive use. Measures of Catholicism that focus on behaviors may better explain opinions about adolescent access to contraception.

The HER Salt Lake media campaign: comparing characteristics and outcomes of clients who make appointments online versus standard scheduling

BACKGROUND

Little research has examined how media outreach strategies affect the outcomes of contraceptive initiatives. Thus, this paper assesses the potential impact of an online media campaign introduced during the last six months of a contraceptive initiative study based in Salt Lake City, UT (USA).

METHODS

During the last six months of the HER Salt Lake Contraceptive Initiative (September 2016-March 2017), we introduced an online media campaign designed to connect potential clients to information about the initiative and a brief (9-item) appointment request form (via HERsaltlake.org). Using linked data from the online form and electronic medical records, we examine differences in demographics, appointment show rates, and contraceptive choices between "online requester" clients who made clinical appointments through the online form (n = 356) and "standard requester" clients who made appointments using standard scheduling (n = 3,051). We used summary statistics and multivariable regression to compare groups.

RESULTS

The campaign logged 1.7 million impressions and 15,765 clicks on advertisements leading to the campaign website (HERSaltLake.org). Compared to standard requesters, online requesters less frequently reported a past pregnancy and were more likely to be younger, white, and to enroll in the survey arm of the study. Relative to standard requesters and holding covariates constant, online requesters were more likely to select copper IUDs (RRR: 8.14), hormonal IUDs (RRR: 12.36), and implants (RRR: 10.75) over combined hormonal contraceptives (the contraceptive pill, patch, and ring). Uptake of the contraceptive injectable, condoms, and emergency contraception did not differ between groups.

CONCLUSION

Clients demonstrating engagement with the media campaign had different demographic characteristics and outcomes than those using standard scheduling to arrange care. Online media campaigns can be useful for connecting clients with advertised contraceptive methods and initiatives. However, depending on design strategy, the use of media campaigns might shift the demographics and characteristics of clients who participate in contraceptive initiatives.

TRIAL REGISTRATION

Clinicaltrials.gov identifier NCT02734199, Registered 12 April 2016-Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT02734199 .

Young women's reproductive health conversations: Roles of maternal figures and clinical practices

OBJECTIVE

To explore the role of clinical providers and mothers on young women's ability to have confidential, candid reproductive health conversations with their providers.

METHODS

We conducted 14 focus groups with 48 women aged 15-28 years (n = 9), and 32 reproductive healthcare workers (n = 5). Focus groups were audio recorded and transcribed. Data were analyzed using inductive coding and thematic analyses. We examined findings through the lens of paternalism, a theory that illustrates adults' role in children's autonomy and wellbeing.

RESULTS

Mothers have a substantial impact on young women's health values, knowledge, and empowerment. Young women reported bringing information from their mothers into patient-provider health discussions. Clinical best practices included intermingled components of office policies, state laws, and clinical guidelines, which supported health workers' actions to have confidential conversations. There were variations in how health workers engaged young women in a confidential conversation within the exam room.

CONCLUSIONS

Both young women and health workers benefit from situations in which health workers firmly ask the parent to leave the exam room for a private conversation with the patient. Young women reported this improves their comfort in asking the questions they need to make the best decision for themselves. Clinic leadership needs to ensure that confidentiality surrounding young women's reproductive health is uniform throughout their practice and integrated into patient flow.

Utilisation of second-trimester spontaneous and induced abortion services in public hospitals in Mexico, 2007-2015

BACKGROUND

Data on utilisation of in-facility second-trimester abortion services are sparse. We describe temporal and geographical trends in utilisation of in-facility second-trimester abortion services across Mexico.

METHODS

We used 2007-2015 data from Mexico's Automated Hospital Discharge System (SAEH) to identify second-trimester abortive events (ICD O02-O08) in public hospitals across Mexico's 32 states. We described utilisation, calculated rates using population data, and used logistic regression to identify woman- and state-level factors (municipality-level marginalisation, state-level abortion law) associated with utilisation of second-trimester versus first-trimester services.

RESULTS

We identified 145 956 second-trimester abortions, or 13.4% of total documented hospitalizations for abortion between 2007 to 2015. The annual utilisation rate of second-trimester abortion remained constant, between 0.5 to 0.6 per 1000 women aged 15-44 years. Women living in highly marginalised municipalities had 1.43 higher odds of utilising abortions services in their second versus their first trimester, when compared with women in municipalities with low marginalisation (95% CI 1.18 to 1.73). Living in a state with a health or fetal anomaly exception to abortion restrictions was not associated with higher utilisation of second-trimester abortion services.

CONCLUSIONS

Our results suggest there is a need for all types of second-trimester abortion services in Mexico. To improve health outcomes for Mexican women, especially the most vulnerable, access to safe second-trimester abortion services must be ensured through the implementation of current legal exceptions and renewed attention to the training of healthcare providers.

Engaging men in an mHealth approach to support postpartum family planning among couples in Kenya: a qualitative study

BACKGROUND

Involving male partners in family planning (FP) education and counseling may improve FP utilization and help meet couples' reproductive health needs in the postpartum period. We aimed to explore Kenyan men's and women's perspectives on an interactive short message service (SMS) approach to support postpartum FP decision-making, and inform intervention content for a randomized controlled trial (RCT).

METHODS

We conducted four focus group discussions (FGD) among men (n = 35) and two among pregnant/postpartum women (n = 15) in western Kenya. Female participants were recruited at antenatal clinics; male participants were referred by antenatal attendees. FGDs included participant critique of pilot theory-based SMS messages. FGD transcripts were coded by two investigators and analyzed using an iterative, modified grounded theory approach. These data informed the intervention and RCT design, in which women had the option to refer male partners for trial enrollment.

RESULTS

Men strongly desired inclusion in FP programs, and frequently discussed negative relationship consequences of women's covert contraceptive use. Female and male participants voiced a variety of concerns about contraceptive side effects and potential harms, which were central to narratives of community influence on personal contraceptive choices. Most participants felt that receiving FP-focused SMS and including men would be beneficial. They perceived that SMS dialogue with a nurse about FP could reduce misperceptions and may stimulate communication within couples, thereby improving contraceptive access and continuation. Shared decision-making around FP within couple relationships, in consultation with clinicians, was highly valued.

CONCLUSIONS

Health concerns about FP and limited couple communication are perceived contributors to postpartum unmet contraceptive need. With women's consent, the inclusion of male partners in FP services, and specifically in an mHealth SMS intervention, is acceptable and desired. Receiving SMS may trigger communication about postpartum FP within couples. SMS content should address contraceptive knowledge gaps, anticipated side effects and FP misperceptions, and allow for real-time method choice assistance.

Motivations and Experiences of People Seeking Medication Abortion Online in the United States

CONTEXT

State legislation restricting access to abortion in the clinic setting raises the possibility that an increasing number of individuals in the United States will self-manage their abortion at home. Medications sourced online represent a potential pathway to abortion self-management. Yet, very little is known about the reasons U.S. residents may seek abortion online or their experiences finding medications and information.

METHODS

In January-June 2017, anonymous in-depth interviews were conducted with 32 people from 20 states who sought abortion medications online (30 women and two men seeking medications for their partners). Participants were asked about their (or their partners') motivations for considering self-managed abortion, the sources of medications they identified and any other methods they considered. Transcripts were coded and analyzed according to the principles of grounded theory.

RESULTS

The analysis revealed four key themes: Seeking abortion medications online can be a response to clinic access barriers both in states with and in ones without restrictive abortion laws; self-managed abortion can be a preference over clinical care; online options offer either information or medications, but not both; and the lack of trusted online options can delay care and lead to consideration of ineffective or unsafe alternatives.

CONCLUSION

Current online options for abortion medications leave many important needs unmet, particularly for women who encounter barriers to obtaining clinic-based abortion services. There is a public health justification to reduce clinic access barriers and to make medication abortion that is sourced online and managed at home as safe and supported as possible.

Access to abortion under the heath exception: a comparative analysis in three countries

BACKGROUND

Despite Britain, Colombia, and some Mexican states sharing a health exception within their abortion laws, access to abortion under the health exception varies widely. This study examines factors that result in heterogeneous application of similar health exception laws and consequences for access to legal abortion. Our research adds to previous literature by comparing implementation of similar abortion laws across countries to identify strategies for full implementation of the health exception.

METHODS

We conducted a cross-country comparative descriptive study synthesizing data from document and literature review, official abortion statistics, and interviews with key informants. We gathered information on the use and interpretation of the health exception in the three countries from peer-reviewed literature, court documents, and grey literature. We next extracted public and private abortion statistics to understand the application of the law in each setting. We used a matrix to synthesize information and identify key factors in the use of the law. We conducted in-depth interviews with doctors and experts familiar with the health exception laws in each country and analyzed the qualitative data based on the previously identified factors.

RESULTS

The health exception is used broadly in Britain, somewhat in Colombia, and very rarely in Mexican states. We identified five factors as particularly salient to application of the health exception in each setting: 1) comprehensiveness of the law including explicit mention of mental health, 2) a strong public health sector that funds abortion, 3) knowledge of and attitudes toward the health exception law, including guidelines for physicians in providing abortion, 4) dissemination of information about the health exception law, and 5) a history of court cases that protect women and clarify the health exception law.

CONCLUSIONS

The health exception is a valuable tool for expanding access to legal abortion. Differences in the use of the health exception as an indication for legal abortion result in wide access for women in Britain to nearly no access in Mexican states. Our findings highlight the difference between theoretical and real access to legal abortion. The interpretation and application of the health exception law are pivotal to expanding real access to abortion.

Factors associated with desired fertility among HIV-positive women and men attending two urban clinics in Lilongwe, Malawi

As access to antiretroviral therapy increases, more HIV-infected patients in sub-Saharan Africa may desire fertility. We conducted a cross-sectional study of reproductive health knowledge, attitudes and practices to identify factors associated with desired fertility among women and men receiving care at two large public HIV clinics in Lilongwe, Malawi. Research assistants administered questionnaires to participants. We performed descriptive, bivariable and multivariable analysis of factors related to desired fertility and of factors related to contraceptive non-use among participants who did not desire fertility. One-third of participants desired future children. Having a partner who desired fertility and having lower parity were associated with desiring children among both genders. For women, believing that pregnancy was unhealthy was associated with decreased fertility desire. Fifty-five percent of women and 69% of men who did not want children in the future reported using contraception at last intercourse. Increasing age, lower parity, and making the decision to use contraception herself were associated with contraceptive non-use among women who did not desire fertility. Having discussed family planning with his partner was associated with contraceptive use among men who did not desire fertility. Knowledge of these factors can guide reproductive health counseling and service provision.

Who presents past the gestational age limit for first trimester abortion in the public sector in Mexico City?

OBJECTIVE

To identify socio-demographic factors associated with presenting for abortion services past the gestational age (GA) limit (12 weeks), and thus not receiving services, in Mexico City's public sector first trimester abortion program.

METHODS

We used clinical data from four high volume sites in the Interrupción Legal de Embarazo (ILE) program, 2007-2015. We used descriptive statistics to quantify the proportion of women who did not receive an abortion due to presenting past the gestational age limit. We used multivariable logistic regression to identify associations between women's characteristics and presenting past the GA limit and calculated predicted probabilities of late presentation for key characteristics.

RESULTS

Our sample included 52,391 women, 8.10% (n = 4,246) of whom did not receive abortion services due to presenting past the GA limit. Adolescents (12-17) made up 8.69% of the total sample and 13.40% of those presenting past the GA limit (p< 0.05). In multivariable analyses, all age groups of adult women had significantly lower odds than adolescents of presenting past the limit (aOR = 0.77, aOR = 0.63, aOR = 0.58 and aOR = 0.37 for 19-24, 25-29, 30-39, and > = 40 years' old respectively). Women living in Mexico City and with higher levels of education had lower odds of presenting past the GA limit, and there was an educational gradient across all age groups. In the multivariable predicted probability models, adolescents at every level of education have significantly higher probabilities of not receiving an abortion due to presenting past the gestational age limit compared with adults (among women with a primary education: 11.75% adolescents vs. 9.02-4.26% across adult age groups).

CONCLUSIONS

Our results suggest that continued efforts are needed to educate women, especially younger and less educated women, about early pregnancy recognition. In addition, all women need information about the availability of first trimester legal abortion to ensure timely access to abortion services.

Factors associated with condom use among men and women living with HIV in Lilongwe, Malawi: a cross-sectional study

BACKGROUND

Understanding the influences on condom use among men and women living with HIV is critical to tailoring sexually transmitted infection/HIV prevention efforts.

METHODS

This is a sub-analysis of a cross-sectional survey including 255 women and 220 men who were sexually active, HIV-positive, and attending HIV care visits in Lilongwe, Malawi. We estimated adjusted prevalence ratios (aPRs) to evaluate for factors associated with consistent condom use (always using condoms in the past month) and use at last coitus for men and women in separate models.

RESULTS

Among women: 38% and 55% reported consistent condom use and condom use at last coitus, respectively. For women, consistent use and use at last coitus were positively associated with the ability to refuse sex without condoms and shared decision-making compared with making the decision alone regarding condom use, and negatively associated with desire for children in the future. Consistent use also increased with longer antiretroviral therapy (ART) use (≥1 year compared with no ART use). Among men: 51% and 69% reported consistent condom use and condom use at last coitus, respectively. For men, the ability to refuse sex without condoms was associated with consistent use and use at last coitus, and believing that condoms should be used with other contraception was associated with consistent use.

CONCLUSIONS

Our findings demonstrate ongoing low condom utilisation among HIV-positive individuals, and highlight that ART and contraceptive use do not deter condom use. Efforts to increase condom utilisation must recognise individual-level factors that influence use and should focus on relationship dynamics and promotion of empowerment and self-efficacy.

To be, or not to be, referred: A qualitative study of women from Burma's access to legal abortion care in Thailand

Background

Reproductive health outcomes among women from Burma who live along the Thailand-Burma border demonstrate an unmet need for access to safe abortion services. In 2014, a multi-national team launched a collaborative three-year initiative to expand a program that refers eligible women for safe and legal abortion care to government Thai hospitals in Tak province, Thailand.

Methods

Over a six-month period we conducted 14 in-depth open-ended interviews with women from Burma who were referred through the program or denied a wanted abortion after being deemed ineligible for referral by staff at the participating clinic. We analyzed the interviews for content and themes using both deductive and inductive techniques.

Results

Women’s experiences accessing legal abortion care were positive and facilitated by appropriate options counseling, logistical support, and financial coverage. Five of the ineligible women we interviewed used traditional methods accessed on both sides of the border to self-induce an abortion and/or visited an untrained and unregulated provider.

Discussion

Our findings highlight the need to redouble efforts to expand access to safe and legal abortion care for women from Burma residing in northern Thailand. Ensuring that women who are denied a safe and legal abortion receive harm reduction interventions and resources is critical.