bluuebunny/crossref_metadata_2025 huggingface dataset:
A Novel IUD Platform Design Uses a Flexible Nitinol Frame to Deliver Either Copper or Levonorgestrel: Phase 2 Data [03I]
Authors: Turok David Keith , Peters Kevin , Katz Bob
Published: April 2020

INTRODUCTION:

Current IUD applicators vary among copper and levonorgestrel devices. We present data on a new intrauterine contraceptive platform that uses a flexible nitinol frame provided in a preloaded applicator with precut strings and a tapered leading edge to deliver either low-dose copper (175 mm2) or a levonorgestrel (52 mg) IUD.

METHODS:

Two Phase 2 studies provide information, one for copper and the other for the levonorgestrel IUD. Subjects met standard inclusion & exclusion criteria for each IUD, per the CDC. IUD placement occurred any day in the menstrual cycle. The primary outcome for both studies was efficacy, measured by Pearl Index (PI). Secondary outcomes include placement success, ease, and pain as well as overall tolerability and safety.

RESULTS:

The copper and levonorgestrel IUD studies enrolled 286 and 279 women, respectively; 60.8% and 64.2% were nulliparous. Investigators described IUD placements as “easy” or “very easy” in 91.5% and 88.9%, while participants rated pain as “moderate” or “very painful” in 19.0% and 21.5%, respectively. Placement required cervical dilation in 41 (14.5%) and 42 (15.1%); 99% of placements were successful in both studies. One pregnancy occurred in the Copper IUD study (PI=0.73, 95% CI 0.09-2.65) and none in the levonorgestrel study (PI=0.0, 97.5% confidence upper bound=1.88). We identified no uterine perforations. First year expulsions occurred in 1 (0.4%) and 7 (2.5%) participants.

CONCLUSION:

This novel IUD platform design successfully delivers both a low dose copper and levonorgestrel IUD with promising efficacy and safety data.
Adoption of a Digital App-Based Fertility Awareness Based Method of Birth Control in the US [04I]
Authors: Pearson Jack T. , Rowland Simon P. , Scherwitzl Elina Berglund , Danielsson Kristina Gemzell , Scherwitzl Raoul
Published: April 2020

INTRODUCTION:

In August 2018 the FDA cleared the first digital app-based fertility awareness method of contraception. We aimed to investigate patterns of adoption of this method since August 2018 and to explore the motivations of women who switched from other methods of birth control.

METHODS:

An electronic web based survey was sent out in the fall of 2018 to Women in the U.S. using the Natural Cycles app as a method of birth control. 1,218 Women responded, answering questions regarding age, marital status, parity, education, religion and political beliefs. Furthermore, they answered questions on their birth control preferences, previous methods, reasons for switching to a digital FABM and their view on the use of the Natural Cycles app.

RESULTS:

Demographics of Natural Cycles Users in the U.S were as follows: Mean age 30, 51% married, 82% nulliparous, 49% bachelor’s degree and 45% no religious belief in particular. The majority of users lived in California and had a presence in New York, Texas and Colorado. 60% of users had switched birth control method twice or more in their lifetime. 71% of users started using Natural Cycles to avoid using hormones.

CONCLUSION:

Over 560,000 women in the us have registered for the app since August 2018, the majority of whom live in California. Demographics of users include approximately 30 years old, in long term relationships, do not have children and are educated. Most of these women are driven to use a digital FABM to avoid the use of hormonal birth control.
Anti-Abortion Picketing and Mental Health: Is There a Correlation Between Picketers and Post-traumatic Stress? [06I]
Authors: Sullivan Richalle , Franklin Tanya , Bergin Ashlee
Published: April 2020

INTRODUCTION:

Previous research has demonstrated that abortion itself doesn’t lead to long term mental health problems. There is a void in the literature in the measurement of and severity of the impact of anti-abortion picketing exposure on patients. This study aims to assess if anti-abortion picketing impacts post-traumatic stress events in patients receiving care at EMW Women’s Surgical Center in Kentucky.

METHODS:

Post-traumatic stress events were measured using the Impact of Events Scale Revised (IES-R), a validated scale that identifies the severity in which respondents experience stress related thoughts and behaviors seven days following an event. Patients seeking surgical abortions were recruited from EMW with informed consent. Participants completed a demographic survey, in which participants estimated the amount of protestors that they encountered and the level of discomfort and harassment experienced. Seven days after the procedure, participants received an email to complete the IES-R assessment, to measure post-traumatic stress events. An objective number of protestors were counted on each day of enrollment.

RESULTS:

A total of 72 participants were enrolled between October 2018 and May 2019. Twenty-five participants (35%) completed the follow-up IES-R survey. Participants who perceived larger number of protestors experienced more discomfort (P=.001) and reported more harassment (P<.001). There was no statistical difference in objective number of protestors and IES-R scores (P=.402). Participants who perceived larger amounts of protestors had significantly higher IES-R scores that met probable PTSD diagnosis (P=.040).

CONCLUSION:

This information highlights how patients’ perception of anti-abortion protestors negatively impacts the mental wellbeing of patients undergoing surgical abortions at EMW.
Comparing the Cardiovascular Risk of Norethindrone Acetate & Levonorgestrel Pills: Is There a Difference? [10I]
Authors: Barnett Clare , Bauerfeind Anja , von Stockum Sophia , Grimes David A. , Heinemann Klaas
Published: April 2020

INTRODUCTION:

Combined oral contraceptives containing norethindrone acetate (NETA) are widely used in the US and globally, but how they compare to levonorgestrel-containing pills is unknown. This pooled analysis compares the safety of NETA and levonorgestrel (LNG) in pills with ethinyl estradiol (EE) ≤30 mcg.

METHODS:

We pooled cohorts of NETA (EE ≤30 mcg) and LNG (EE ≤30 mcg) users from four large prospective, controlled, non-interventional, cohort studies in 14 European countries, US and Canada. Baseline characteristics, including reproductive, contraceptive and medical history, were summarized using descriptive statistics. Propensity score sub-classification was applied to balance baseline characteristics between cohorts. Time-to-event analysis of venous and arterial thromboembolic events was carried out based on the extended Cox model to calculate crude and adjusted hazard ratios with 95% confidence intervals.

RESULTS:

Approximately 80,000 women contributed 145,000 women years of exposure. The prevalence of prognostic factors at baseline showed typical features of US and European oral contraceptive users. A comparison between NETA vs LNG showed no significant difference in the risk of venous thromboembolism: adjusted hazard ratio 0.73 (95% CI 0.48-1.11). A similar result was observed considering the risk of arterial thromboembolism (adjusted hazard ratio 0.89 [95% CI 0.42-1.89]).

CONCLUSION:

Low-dose oral contraceptives containing NETA and LNG are associated with similar low risks of venous and arterial disease. This analysis provides reassurance for both women and clinicians regarding the safety of contemporary oral contraceptives.
Contraception Counseling and Use Among Adolescent and Young Adult Women Undergoing Cancer Treatment [11I]
Authors: Abelman Sarah , Cron Julia
Published: April 2020

INTRODUCTION:

Adolescent and young adult women undergoing cancer treatment face unique reproductive health risks. The objectives of this study were to assess the prevalence of pregnancy prevention counseling and contraception use in the oncology setting, and to identify patient factors associated with these outcomes.

METHODS:

After institutional review board approval, a retrospective chart review was conducted of female patients ages 15-25 receiving cancer treatment, excluding those treated with only surgery, at Yale New Haven Hospital from 2013-2018. Univariate and multivariate logistic regression were used to assess the relationship between patient variables and the outcomes of counseling and contraception use.

RESULTS:

157 patients were included in this analysis; the median age was 20, and the most common diagnoses were hematologic (40.8%) and thyroid (31.2%) malignancies. Treatments received included various combinations of surgery, chemotherapy, radiation, hormone therapy, targeted or biologic agents, and bone marrow transplant. 33.1% were documented as receiving reproductive health counseling and 48.4% used contraception. Younger patients (ages 15-20) were less likely to receive counseling (OR 0.31, 95% CI 0.14-0.70, P=.005). Receiving counseling (OR 3.36, 95% CI 1.35-8.34, P=.009) and sexual activity (OR 4.18, 95% CI 1.80-9.68, P=.001) were significantly associated with contraception use.

CONCLUSION:

Reproductive health counseling was documented infrequently during oncologic care for adolescent and young adult women, especially for younger patients. However, such conversations were associated with a higher likelihood of contraception use. There is a clear need to improve rates of counseling in this high-risk setting, especially with adolescents who may be more vulnerable when it comes to reproductive health.
Does Immediate Post-abortion Long-Acting Reversible Contraception Reduce Rates of Repeat Abortion? [14I]
Authors: Hershman Sarah R. , Reider Mitchell W.
Published: April 2020

INTRODUCTION:

Despite overall declining abortion rates in the US, rates of repeat abortion remain high, and previous unplanned pregnancy or elective abortion are significant risk factors for future abortions. This research aims to examine whether immediate no-cost post-abortion placement of long-acting reversible contraception (LARC) is associated with decreased chance of having a repeat abortion, compared to similar patients who did not opt for immediate LARC.

METHODS:

We conducted a retrospective cohort study using records from an abortion provider where no-cost post-abortion LARC devices were available to patients. We reviewed surgical abortions between September 2015 and February 2016 (LARC cohort, n=117; no-LARC cohort, n=154), and assessed the rate at which they returned for repeat abortion at the same facility within 3 years. This study was approved by Cleveland Clinic IRB.

RESULTS:

During the 3-year rolling follow-up period, for the LARC group there were 15 patients (12.8%) returning for a total of 20 abortions, compared with the no-LARC group, who had 50 patients (32.5%) return for a total of 86 abortions. The relative risk of any repeat abortion within 3 years was 0.39 for the LARC group (95% CI 0.24–0.67).

CONCLUSION:

Immediate post-abortion LARC is associated with significantly lower rate of repeat abortion within the next 3 years. Immediate post-abortion LARC should be offered to all patients undergoing elective surgical abortion. These findings should be used to inform healthcare policy, with a goal of reducing rates of repeat elective abortion.
Exploring the Role of Medicaid as a Payer for Long-Acting Reversible Contraception in the Private-Practice Setting [17I]
Authors: Howard David L. , Ford Avery , Ceballos Sonia , Volker Warren
Published: April 2020

INTRODUCTION:

To assess temporal trends in the role of Medicaid as a payor for intrauterine devices and contraceptive implants in the private-practice setting.

METHODS:

This was a retrospective cohort study. We studied women receiving insertions of long acting methods of reversible contraception (LARCs) between January 1, 2013, and December 31, 2016 (n=3,477 women). The exclusive data source was billing records. The setting was a large multi-specialty private practice in Las Vegas, Nevada.

RESULTS:

Between January 1, 2013, and December 31, 2016, there were 3,477 insertions of LARCs. Of this number, 400 (11.5%) were paid for by Medicaid/self-pay, and 3,077 (88.5%) were paid for by private insurance. Among LARC users 30 years and older, the proportion that had their device paid for by Medicaid/self-pay increased from 4.3% in 2013 to 12.1% in 2016 (OR 3.09 [95% CI 1.68-5.68] P<.001). The proportion paid for by Medicaid/self-pay was actually stable from 2013 to 2015 (4.3%, 3.4%, 5.5%) with a jump in 2016 (to 12.1%). Among LARC users under 30 years, the proportion that had their device paid for by Medicaid/self-pay increased from 6.0% to 26.3% over the same period (OR 5.63 [95% CI 3.35-9.49] P<.001). The increase was progressive (6.0% to 9.0% to 13.0% to 26.3%).

CONCLUSION:

In this large private-practice setting, the proportion of LARCs paid for by Medicaid increased significantly over time, particularly in women under 30 years old. We believe our findings have policy implications in the context of the current, sometimes aggressive, political attempts to roll back the expansion of Medicaid that was a crucial component of the Affordable Care Act.
Improving Access to Long-Acting Reversible Contraception in Eastern North Carolina [20I]
Authors: Gautam Amber
Published: April 2020

INTRODUCTION:

More than half of mothers in eastern NC present with unintended pregnancy, a major contributor to infant mortality rate. LARCs have been shown to be the most effective form of reversible contraception. However, access to LARCs continues to be a challenge for many patients here. This study aims to quantify the rate of postpartum mothers who received LARCs of those who expressed a desire postpartum.

METHODS:

Over 361 women who delivered at Vidant Medical Center were included. Retrospective chart review was performed documenting desired contraception, whether the patient received it inpatient, attendance of postpartum visit, and contraceptive method received. Of 361 patients reviewed, 327 postpartum contraceptive plans were visible.

RESULTS:

Of the 327 women who were reviewed, 262 attended their postpartum visit. Of the 49 women who expressed desire for etonogestrel implantable device (Nexplanon) at the time of discharge, 27 received an etonogestrel implantable device at their postpartum visit (55.1%). Of the 69 women who expressed interest in receiving an intrauterine device at the time of discharge, 31 women received it at their postpartum visit (44.9%).

CONCLUSION:

There is a marked discrepancy in the number of women who express interest in receiving LARCs and those who actually end up receiving them. By offering placement in the immediate postpartum period, an increase in the number who receive LARCs who desire it is anticipated. Inpatient offering of both forms of LARCs started in December of 2018; data collection is currently in process with updated outcomes.
Insertion-Related Pain and Short-Term Satisfaction With Two Copper IUDs: A Randomized Trial [22I]
Authors: Burke Anne E. , Edelman Alison , Chen Beatrice A. , Castano Paula , Chen Pai-Lien
Published: April 2020

INTRODUCTION:

Pain during intrauterine device (IUD) insertion is a barrier to uptake. We compared insertion-related pain and short-term satisfaction between two copper (Cu) IUDs.

METHODS:

We conducted a multicenter, single-blind randomized trial comparing two CuIUDs. Participants were randomized (4:1 ratio) to a smaller (Mona Lisa NT Cu380-Mini [24 mm x 30 mm]) or standard (Paragard TCu380A [32 mm x 36 mm]) CuIUD. Participants recorded maximum pain levels on a 10 cm visual analog scale at nine timepoints (pre- and immediately post-IUD insertion, daily for 7 days). At day 7, participants reported overall satisfaction (5-point scale) and whether they would recommend the product to others. For each timepoint, we computed mean pain level and mean change in pain from baseline, and stratified by parity. We used T-tests and chi-square tests to compare results between products.

RESULTS:

We enrolled 1,105 women, 84% nulliparous (n=924). Mean pain levels immediately post-insertion were 4.9 cm (SD 2.3) for both the smaller (n=886) and standard (n=219) products. Subsequent pain levels decreased equally across both products, from 2.5 cm (day 2) to 0.7 cm (day 7). Mean pain after baseline adjustment was similar between products. Nulliparous women using either IUD reported higher pain levels at all timepoints than parous women (P<.05). Among nulliparous women, 54% were highly satisfied with the smaller versus 45% with standard IUD (P<.05); over 92% using each product would recommend it. Parous women reported similar satisfaction by product.

CONCLUSION:

Reported pain was similar between IUDs. Satisfaction among nulliparous women was higher at 7 days with a smaller CuIUD. Longer-term data may elucidate possible differences between products.
Medical and Ethical Analysis of Menstrual Apps [26I]
Authors: Gross Marielle S. , Corbin Bethany , Miller Robert C.
Published: April 2020

INTRODUCTION:

The recent explosion of digital health applications includes emergence and growing popularity of smartphone apps for women’s health, most commonly menstrual tracking apps. Meanwhile, monetization of women’s sensitive health data has led to public outcry and ethical concerns. Greater understanding of medical and ethical aspects of menstrual app use is needed.

METHODS:

We survey women’s menstrual app use, highlighting issues related to beneficence, autonomy and justice.

RESULTS:

These technologies may benefit women by empowering better control over contraceptive intentions or pregnancy desires and greater insights into reproductive health, however harms may occur when technology fails, most notably in the case of unintended pregnancies among women using apps with flawed ovulatory prediction algorithms. Autonomy may be compromised if women cannot control third-party use of highly sensitive reproductive health data (e.g., when, where and who they have sex with), particularly when ability to use apps is conditioned on “accepting the cookies” and potentially misleading small-print notice/informed consent regarding reasonable expectations of privacy and potential data uses. These apps normalize a new frontier for ubiquitous data surveillance, gathering health-relevant data outside of the traditional healthcare contexts where it is not afforded appropriate legal or ethical protection. Menstrual apps may promote commodification of women’s bodies by harnessing personal data to generate advertisement revenue.

CONCLUSION:

Current menstrual apps raise concerns regarding their effectiveness for promoting women’s health, expectations of privacy and appropriateness of monetization of inherently sensitive health data. Emerging technologies such as blockchain and privacy-preserving computation may support more woman-centric menstrual apps; further research is warranted.
Medical Crowdfunding for Abortion Services [27I]
Authors: Solotke Michael T. , Ross Joseph , Cron Julia
Published: April 2020

INTRODUCTION:

Crowdfunding involves soliciting donations, often over internet platforms, to fundraise for a specific need. Although crowdfunding for medical expenses has grown in popularity, one important and understudied application of crowdfunding is abortion services. Given the access barriers and political nature of abortion, many women seeking these services may turn to more anonymous options for support, including crowdfunding. We therefore examined such utilization of crowdfunding in the United States.

METHODS:

This study is a cross-sectional analysis of all campaigns for abortion services on four major crowdfunding sites. Two authors reviewed all campaigns included in our study, abstracting the following information: whether the campaign was successfully funded, number of donations, number of social media shares, number of campaign updates, campaign duration, age of woman, gestational age, state abortion policy, insurance status, number of words in campaign description, narrative point of view, stated purpose of funds, and 10 campaign themes.

RESULTS:

Among 92 crowdfunding campaigns, the total amount requested was $118,272 and the total amount raised was $36,085. The median amount requested was $610 (IQR $500-$1,000), median raised was $0 (IQR $0-$444), and 19 (21%) campaigns successfully reached their fundraising goal. Campaign success was not statistically different in states with very hostile (33%), hostile (36%), middle-ground (9%), supportive (17%), and very supportive (11%) abortion policies (P=.08). Campaigns written in third person or describing maternal/fetal complications raised significantly more money.

CONCLUSION:

Although crowdfunding is used to finance abortion services, it has a low success rate and raises ethical concerns.
Men’s Condom Use at Coitarche: An Analysis of National Survey of Family Growth Data (2006-2013) [28I]
Authors: Nguyen Brian T. , Violette Caroline
Published: April 2020

INTRODUCTION:

Interventions to prevent unplanned pregnancy cannot overlook the role of young men. Using National Survey of Family Growth data from 2006 to 2013, we characterized men reporting having not used a condom at their first intercourse (coitarche) with a non-steady partner, as well as associated factors.

METHODS:

Survey respondents who reported ever having intercourse were asked about contraception used at coitarche, inclusive of male and female methods. Analysis was restricted to respondents whose first sexual partner was an unsteady partner, thereby comprising a population for whom condoms are recommended for preventing both pregnancy and sexually transmitted infections. Demographic and behavioral factors were examined against condom use, with significant associations included in multivariable logistic regression. Bivariate associations of condom use with receipt of specific sex education topics are described.

RESULTS:

The odds of unprotected coitarche decreased by nearly 25% between 2006 and 2010 and 2011 and 2013. Older respondents had 2.0-4.0 (95% CI 1.6-5.3; P<.01) times the odds of unprotected coitarche compared to those below age 19. Other independently associated factors included coitarche before age 15 (OR 3.0; 95% CI 2.6-3.6; P<.01) and with an older-aged partner (OR 1.7; 95% CI 1.4-2.0; P<.01). Among respondents who received sex education prior to coitarche, discussion of STIs and contraception were associated with condom use at coitarche; abstinence-only education was not associated.

CONCLUSION:

Nearly 1 in 5 young men reported not using a condom at coitarche with an unsteady partner. Prevention efforts should continue to evaluate psychosocial and structural reasons why young men do not use condoms.
Vasectomy: A Survey of Urologist’s Opinions on Training Family Planning Providers [37I]
Authors: Xepoleas Meredith D. , Nguyen Brian T. , Patel Jasmine
Published: April 2020

INTRODUCTION:

Vasectomy is one of the only forms of male-controlled contraception, yet it is the only form of contraception not generally performed by traditional family planning providers: family medicine physicians and obstetricians/gynecologists (OB/GYNs). Our study aims to assess the willingness of urologists to train family planning providers on this procedure.

METHODS:

For this IRB approved/exempt study, electronic surveys were sent to all American urology residency program directors via REDCap. In addition, in person surveys were conducted at the American Urology Association (AUA) 2019 Conference. Statistical analyses were performed using Student t-tests for continuous data and Pearson chi-squared tests for categorical data.

RESULTS:

Forty-nine AUA conference responses and 26 residency program director responses were collected. Most urologists surveyed were willing to train other urologists (85.1%), while they were less willing to train non-urologists: general surgeons (20.3%), family medicine physicians (20.3%), and OB/GYNs (10.8%). While more urologists were willing to train family medicine physicians versus OB/GYNs (P<.01), more urologists believed it would be more difficult for family medicine practitioners to learn vasectomy (P<.01). Urologists were worried about competition, that training others would decrease cases for urologists, and family planning providers would have insufficient volume. In addition, urologists were concerned that family medicine physicians had a lack of surgical skills and OB/GYNs would be unfamiliar with anatomy.

CONCLUSION:

Overall, urologists show an unwillingness to train family planning providers. In order to provide comprehensive care, family planning providers should find allies to help learn the procedure or partner with vasectomy providers.
Workflow Process Mapping: A Novel Approach to Promote Implementation of Evidence Based Practices [39I]
Authors: Bonawitz Kirsten , Finer Zoe , Heisler Michele , Wetmore Marisa , Dalton Vanessa , Moniz Michelle
Published: April 2020

INTRODUCTION:

National guidelines recommend offering immediate postpartum long-acting reversible contraception (LARC). However, hospitals lack evidence-based approaches for embedding this care into existing workflow. We used a multiple case study to understand immediate postpartum LARC workflow at early-adopter sites and create a tool to help embed this care into practice at new sites.

METHODS:

A systematic literature search identified hospitals offering immediate postpartum contraceptive care. We purposively sampled information-rich sites. From 8/2017 to 9/2018, we conducted site visits with semi-structured key informant interviews informed by the Consolidated Framework for Implementation Research (CFIR). Workflow process mapping was used to develop detailed workflow maps and describe drivers of observed workflow variation. Institutional IRB approval was obtained.

RESULTS:

After interviewing 79 key informants at 11 hospitals, workflow process mapping revealed variation across sites, especially related to timing and staff involved in 1) counseling, consent, and documentation of patient preferences, 2) addressing insurance coverage, 3) device ordering, 4) contraceptive insertion technique, and 5) post-insertion management. Observed variation was often driven by context (e.g., degree of integration between inpatient and outpatient teams, variation in L&D staff composition) and gaps in clinical evidence (e.g., uncertainty about the comparative effectiveness of intrauterine device insertion techniques). Only two sites prospectively designed a workflow. At other sites, workflows were often inefficient, requiring adaptations after initial implementation and clarification about roles and responsibilities.

CONCLUSION:

Pre-implementation workflow process planning using the self-assessment tool may help sites engage key stakeholders, customize workflow to local needs, and minimize need for future adaptations.
“Part Triage, Part Gatekeeping”: A Qualitative Assessment of Prescribing Gender-Affirming Hormones [40I]
Authors: Stroumsa Daphna , Moravek Molly B. , Wu Justine P. , Toman Lindsay
Published: April 2020

INTRODUCTION:

The requirement for mental health evaluation prior to initiation of gender-affirming hormones for transgender patients is at the center of an active debate in the field. While some prescribers adhere to this requirement, which arises from historical professional guidelines, others do not require universal mental health evaluation. Current guidelines leave room for variability in clinical pathways to hormone initiation, and prescribers must navigate these variations. We aim to understand different approaches providers use in clinical decision-making regarding hormone initiation, and to assess factors that affect these approaches.

METHODS:

Semi-structured interviews were conducted with prescribers of gender affirming hormones between May and October of 2019 (n=19). Respondents were purposefully sampled to include those who indicated that they required mental health evaluation prior to hormone initiation, and those who did not. Interviews were transcribed verbatim and coded using a grounded-theory informed approach.

RESULTS:

Themes related to factors that influence clinical decision-making included patient safety; limitations of professional role and expertise; availability of resources; and concerns about patient access to care. Prescribers navigate along a continuum rather than adhering to strict rules about mental health evaluation; factors that influence these decisions include patient resources, treatment access, professional roles and ethical obligations to the patient. The role of mental health evaluation is viewed as a combination of a triage necessity to identify appropriate candidates, and as a gatekeeping practice that limits care accessibility.

CONCLUSION:

Providers practice on a continuum of care rather than divided along binary lines regarding requirement for mental health evaluation.
Breast Symptoms After Pregnancy Loss and Abortion: An Observational Study [03J]
Authors: Hagey Jill M. , Truong Tracy , Deans Elizabeth I.
Published: April 2020

INTRODUCTION:

We aimed to determine the prevalence, duration and bother of breast symptoms (engorgement, tenderness and leakage) after 1st and 2nd trimester pregnancy loss and abortion; an under-studied area in obstetrics and gynecology.

METHODS:

We enrolled a convenience sample of 86 patients seen for pregnancy loss and abortion services at the Duke Family Planning Clinic. Participants were surveyed using the Bristol Breast Symptoms Inventory on the day of medical or surgical abortion, after three to four days, and at two weeks.

RESULTS:

Of the patients enrolled, 59 were in their 1st trimester and 27 were in their 2nd trimester. The average age was 32; the majority of patients had a prior pregnancy and were white or African American.

At time of presentation, 42% reported engorgement, 61% reported tenderness, and 6% reported leakage. The majority of patients with tenderness or engorgement reported the symptoms as bothersome and this proportion increased as time progressed. First trimester patients’ symptoms decreased over time, while symptoms persisted for 2nd trimester patients. At two weeks, 40% of 2nd trimester patients reported engorgement, 50% reported tenderness, and 20% reported leakage. There were no differences in symptoms by route of or reason for abortion.

CONCLUSION:

Breast engorgement and tenderness are common and bothersome following pregnancy loss and abortion. Breast symptoms can persist for many patients with pregnancy loss or abortion in the 2nd trimester. Determining those at higher risk for breast symptoms and adapting procedural counseling to address these symptoms may improve patient-centered care.
Changes in Young Pro-Choice Physicians' Attitudes Towards Abortion Provision in Residency and Early Practice [05J]
Authors: Payne Carolyn , Frankel Angela
Published: April 2020

INTRODUCTION:

This study sought to identify factors in OBGYN or Family Medicine residency training that support or impede a highly motivated physician from providing abortion care after residency.

METHODS:

Residents who desired abortion training at the onset of residency were recruited via purposeful sampling and snowball sampling techniques. Participants were queried about medical training and factors influencing future abortion provision via online survey and semi-structured phone interview.

RESULTS:

Eighty-two individuals in residency and early practice completed the survey (65.6% response rate), and 26 physicians participated in phone interviews. Thirty percent felt that they received insufficient abortion training (particularly in second trimester procedures), 58% of respondents were involved with pro-choice organizations prior to residency, compared to 43.3% reported involvement during residency. While 60% considered pursuing family planning fellowship (FPF), only 22% of respondents applied. Of those who did not apply, the most commonly reported reasons were: belief that skills acquired in residency were sufficient (44%), desire to practice full-spectrum care after residency (42%), and lack of interest in conducting research (23.7%). Excluding FPF trainees, only 21% of phone interview participants were satisfied with their current level of abortion provision. Common barriers to provision included employer restrictions, competing clinical interests, lack of mentorship/community, and regional clustering of providers.

CONCLUSION:

Interventions seeking to increase abortion provider availability should be directed toward bolstering family planning mentorship and community in residency, challenging institutional restrictions that impede comprehensive training, and incentivizing trained providers to seek geographically diverse positions that enable abortion provision in practice.
Distance Traveled for Abortion at a Southern Tertiary Care Center Following Restrictive Legislation [10J]
Authors: Brenner Tara F. , Stuart Gretchen S. , Rowe Carly
Published: April 2020

INTRODUCTION:

North Carolina enacted five statutes restricting abortion between 2011 and 2016. Our objective was to compare the proportion of women who traveled more than 25 miles to a southern tertiary care center in 2011 to the proportion of women who traveled more than 25 miles to this center in 2017.

METHODS:

We conducted a time-series retrospective cohort study of women who obtained an abortion at University of North Carolina Hospitals in 2011 and 2017. We collected data regarding residence, demographics, gestational age, indication, parity, and referral source. Our primary outcome was distance from self-reported residence to the study center.

RESULTS:

We enrolled 405 women, 143 in 2011 and 262 in 2017; groups were similar in age, parity, and ethnicity. In 2011, 72% (103/143) traveled more than 25 miles, compared with 75% (196/262) in 2017 (P=.473). In 2011, the maximum miles traveled was 290 compared to 420 in 2017. More women from neighboring states were seen in 2017 than 2011. Women seeking abortion in 2017 were four times more likely to have been referred from a freestanding abortion clinic compared with women in 2011 (38% [39/262] vs 9% [13/143]).

CONCLUSION:

In our tertiary care center, there was no difference in distance traveled for abortion before and after the legislative changes. However, the increased number of women seen from outside health centers and neighboring states following the legislative session may indicate additional barriers to abortion access, potentially related to increased time commitment, number of visits, and number of open clinics.
First-Year Side Effect Rates in Nulliparous and Parous Levonorgestrel 52 mg Intrauterine System Users [12J]
Authors: Cwiak Carrie , Blumenthal Paul D. , Kerns Jennifer , Westhoff Carolyn , Olariu Andrea I. , Creinin Mitchell D.
Published: April 2020

INTRODUCTION:

We investigated the impact of parity on side effects during the first year after levonorgestrel 52 mg intrauterine system (IUS) placement.

METHODS:

We evaluated data from the ongoing 10-year Phase 3 Liletta® study in which 1,714 women aged 16-45 years received an IUS. Subjects reported side effects during follow-up visit interviews. For this analysis, we only included women with at least one 28-day cycle of follow-up and excluded women using a levonorgestrel IUS in the month before enrollment. Side effects evaluated at six and 12 months included abdominal pain, acne, anxiety/panic issues, depression, diarrhea, dyspareunia, fatigue, gastritis/reflux, headache, mastalgia, mood changes, nausea or vomiting, orgasm/libido problems, pelvic pain, vaginal discharge/odor, and weight changes. We used Fisher exact tests for all comparisons.

RESULTS:

The dataset included 931 nulliparous and 613 parous women. Over the first six and 12 months, the most common complaints were acne (158 [10.2%] and 193 [12.5%], respectively) and headache (87 [5.6%] and 104 [6.7%], respectively). Only acne differed by parity, being more common among nulliparous women at both six (112 [12.0%] vs 46 [7.5%], P=.005) and 12 months (134 [14.4%] vs. 59 [9.6%], P=.006). When evaluating only women who did not use combined hormonal contraception (CHC) in the month before enrollment, nulliparous (n=445) and parous (n=414) women had no significant difference in side effects at six or 12 months.

CONCLUSION:

Side effects did not differ by parity during the first year of levonorgestrel 52 mg IUS use except acne reported more frequently by nulliparous than parous women. However, this difference may be more related to CHC discontinuation than IUS initiation.
Immediate Post Placental IUDs: Are Removal Complications Increased? [13J]
Authors: Knapke Lindsey , Hade Erinn , Isley Michelle Marie
Published: April 2020

INTRODUCTION:

Post-placental intrauterine device (IUD) insertion is associated with increased risk for expulsion and missing strings at follow up. We evaluated the proportion of non-visualized strings and complicated IUD removals in patients who had post-placental IUDs placed at the time of vaginal delivery or cesarean section.

METHODS:

We performed a single site retrospective cohort study of women who had an IUD placed at either the time of cesarean section or vaginal delivery from January 2016-January 2019. The primary outcome was identification of the IUD strings at a postpartum or emergency department visit. IRB approval was obtained. Demographic, obstetric and clinical characteristics were summarized through descriptive statistics, and 95% confidence intervals summarized variability. Fisher’s exact test was utilized to provide unadjusted comparisons between groups.

RESULTS:

A total of 253 women had a post-placental IUD. Fifty-four percent had IUD insertion after vaginal delivery and 46% after cesarean section. Of these 253 women, 66% (n=167) had documented follow up visits. Of the 167 women with follow up, strings were visualized in 52% (95% CI 44, 59%). Strings were not visible in 31% (n=52) or were not assessed or previously expulsed in 17% (n=29). The proportion of women with non-visible strings was not different between vaginal (45%) versus cesarean (53%) deliveries (Fisher’s exact p-value: 0.28). Among those with non-visualized IUD strings, 11.5% (n=6) required complicated removal.

CONCLUSION:

Post-placental IUD insertion was associated with a substantial proportion of non-visible strings in the post-partum setting, leading to a higher potential for complicated IUD removals and need for improved patient counseling.
Improving Access to Immediate Postpartum LARC: A Quality Improvement Project [15J]
Authors: Cunningham Heather E. , Flicker Amanda
Published: April 2020

INTRODUCTION:

Access to immediate postpartum long acting reversible contraception (LARC) can aid in pregnancy spacing and avoidance of complications associated with unintended and short interval pregnancies. Comprehensive prenatal counseling includes the full spectrum of contraceptive options, ideally available regardless of ability to pay.

METHODS:

A multidisciplinary team including representatives from pharmacy, billing, coding, nursing, and the OB/GYN department was created to implement an immediate PP LARC program at a community/academic hospital without access to grant funding. Baseline provider knowledge of immediate postpartum LARC was determined via a department wide survey. Education was then provided via didactic lectures and simulated post-placental IUD placement. Billing and coding terms were clarified for inpatient use of copper containing IUD, levonorgestrel-releasing IUD, and etonogestrel implant. Patient counseling and inpatient documentation templates were created for provider use.

RESULTS:

Based on survey results, provider knowledge of LARC improved after didactic education and simulation training. Within the first 3 months of implementation (4/16/19 to 7/31/19), 42 inpatient LARCs were provided. Of these, 69% were IUDs and 31% were implants. Data collection is ongoing and seeks to determine the impact of this implementation on adolescent and short interval pregnancy rates.

CONCLUSION:

It is feasible to implement an immediate postpartum LARC program in less than one year when utilizing a multidisciplinary approach. While grant funding is not necessary for the provision of this service to patients with medical assistance, ongoing quality improvement will necessitate advocacy at a state level in order to provide inpatient coverage for women with private insurance.
Influence of Access to Immediate Postpartum LARCs on Interpregnancy Interval [16J]
Authors: Bakk Juliana , Patel Kriya , Pensak Meredith , DeFranco Emily
Published: April 2020

INTRODUCTION:

Assess the effect of immediate access to postpartum (PP) LARCs (long-acting reversible contraceptives) and contraceptive access through Medicaid expansion (ME) on short interpregnancy interval (IPI) rates in the US.

METHODS:

Population-based retrospective cohort study of all US live births, 2016 (n=3,956,112), using Birth Certificate data. We categorized states into those that adopted Medicaid expansion (+ME), which improves access to PP contraception, and states that provide access to immediate PP-LARCs (https://www.acog.org/About-ACOG/ACOG-Departments/Long-Acting-Reversible-Contraception/Immediate-Postpartum-LARC-Medicaid-Reimbursement). States were classified as: (1) +ME/+LARC, (2) +ME/-LARC, (3) –ME/+LARC, (4) –ME/-LARC. Births from 13 states who adopted ME after 1/1/2014 were not included. Multivariate logistic regression estimated the relative influence of ME and PP-LARCs on the outcome of short IPI (<12 months), after adjusting for maternal race, age, marital status, and WIC.

RESULTS:

The study population comprised 1,831,665 births to multiparous women with data on IPI among included states. Of those, 50% were in 19 states with +ME/+LARC, 151,999 (8%) in 5 states with +ME/-LARC, 742,836 (40%) in 12 states with –ME/+LARC, and 3,876 (0.2%) in one state with –ME/-LARC. The rate/risk of short IPI was lowest in states with ME plus immediate PP-LARC access (16.17%, 95% CI 16.09-16.25%), adjusted RR 0.926, 95% CI 0.92-0.93). Short IPI rates and adjusted risks were slightly higher in states that adopted only one program or neither: +ME/-LARC 18.05% (CI 17.86-18.25%), -ME/+LARC 18.12% (CI 18.03-18.20%), -ME/-LARC 18.83% (CI 17.60-20.06%), with highest risk in the state with –ME/-LARC, adjRR 1.12, CI 1.05-1.19.

CONCLUSION:

These data demonstrate that both Medicaid expansion and access to immediate PP LARCs decrease the frequency of short IPI, which may reduce adverse birth outcomes in the US associated with insufficient birth spacing.
Medical Comorbidities as Reason for Referral and Delayed Termination in New Jersey Women [19J]
Authors: Unsal Aylin , Vlahos Alec , Segui Morit , Musa Tina , Brandi Kristyn , Barlog Lauren
Published: April 2020

INTRODUCTION:

Women seeking abortion are commonly referred to multiple providers secondary to medical comorbidities. This study aims to characterize correlation of medical comorbidities and delayed access to abortion in New Jersey (NJ), a state with few abortion restrictions.

METHODS:

This prospective cross-sectional study surveyed NJ women seeking abortion care at University Hospital (UH) in Newark, using questions from the Guttmacher Institute’s “National Survey of Women Having Abortions”. IRB approval and informed consent were obtained prior to patient enrollment. Cross-sectional comparisons were made using Wilcoxon rank-sum tests and likelihood-ratios.

RESULTS:

Of 121 women, 67 (56.8%) reported abortion denial at another clinic; within that subgroup, 46 (68.7%) cite medical comorbidities as a reason for referral. Referral secondary to medical comorbidity is associated with increased time to abortion compared to those that presented to UH initially (40.5+/-29.0 vs. 24.1+/-21.3 days, P=.0003). Prior cesarean delivery (CD), fibroids, placenta pathology, and obesity are most common. Medical comorbidity necessitating referral is significantly associated with increased travel distance (41.1+/-42.6 vs. 10.8+/-22.1 miles, P<.0001), particularly in patients with previous CDs (P=.0023). Only prior CD and placental pathology are associated with increased time to abortion (33.9+/-28.3 vs. 60.0+/-29.0 days, P=.014; 32.7+/-26.1 vs. 50.3+/-35.1 days, P=.03, respectively).

CONCLUSION:

Medical justification for referral is associated with delayed access to abortion. Understanding risk of morbidity in abortion in patients with placental pathology or prior CD may prevent unnecessary referral and delay in care for these women.
Postpartum Contraception by Pregnancy Intent in a Cohort of Women at an Urban Academic Health Center [22J]
Authors: St. John Meghan , Sullivan Kirby , DeFranco Emily , Kelly Elizabeth A.
Published: April 2020

INTRODUCTION:

Nearly half of all pregnancies are unintended. We aim to understand postpartum contraceptive preferences in the context of pregnancy intention (PI).

METHODS:

Prospective cohort study analyzing postpartum contraceptive behaviors in 431 postpartum women who delivered at the University of Cincinnati Medical Center. Postpartum contraceptive choice (PCC) was compared between women with intended and mistimed/unintended pregnancies, classified using an adapted National Survey of Family Growth construct. Regression analysis estimated the influence of PI on PCC.

RESULTS:

71.9% of all pregnancies were unintended. They are more likely in women who are non-Hispanic black (62.3%), unmarried (86.3%), between 18 and 24 years old (51.3%), and use Medicaid (80.1%), compared to intended pregnancies, p-value<0.001. The most popular choices of postpartum contraception overall were IUDs (21.4%), BTL (20.7%), and Depo-Provera (20.2%). Women with unintended pregnancy were 83% more likely to choose highly effective, user-independent methods compared to any other or no method, RR 1.83 (95% CI 1.36, 2.47), and especially more likely to desire sterilization BTL, RR 2.7 (95% CI 1.58, 4.59). Among women sure of their PCC, those with unintended pregnancy were still >50% more likely to use highly effective, user-independent methods compared to user-dependent methods, RR 1.56 (95% CI 1.18, 2.06).

CONCLUSION:

Women with unintended pregnancy are significantly more likely to choose highly effective postpartum contraception but are also more likely to be medically underserved. Public health initiatives to improve access to family planning services and PPC are important areas of focus to address the high rate of unintended pregnancy.
Reproductive Health Goals and Experiences of Women With Cystic Fibrosis [24J]
Authors: Leech Mary M. , Stransky Olivia M. , Roe Andrea H. , Kazmerski Traci M.
Published: April 2020

INTRODUCTION:

Treatment and management advances are allowing women with many chronic diseases, such as cystic fibrosis (CF), to live longer, healthier lives. As survival improves, addressing women’s sexual and reproductive health (SRH) is increasingly important. This study examines the reproductive goals and experiences of women with CF to inform the development of a disease-specific, patient-centered decision aid (DA) around SRH.

METHODS:

Adult women with CF participated in individual, semi-structured interviews exploring their experiences and attitudes toward parenthood, pregnancy, contraception, and SRH care provision. Interviews were audio-recorded and transcribed verbatim. Qualitative analysis was conducted using a thematic analysis approach. IRB approval was obtained (#STUDY19040336).

RESULTS:

To date, 20 women with CF (age 20-63 years) have been interviewed. Emerging themes include: 1) CF team as a de facto primary care provider and related gaps in SRH care provision; 2) Lack of shared language between patients and providers related to SRH care; 3) Impact of CF on the ability to parent; 4) SRH has low priority or is perceived as unconnected to standard CF care; 5) An evidence-based reproductive goals DA would facilitate shared SRH decision-making with CF care teams.

CONCLUSION:

Women with CF often experience disjointed SRH care and would benefit from the development of a DA that supports them in recognizing and realizing their reproductive goals. Results from this work can serve as a model for the development of interventions that improve patient-centered SRH decision-making, especially for women with other chronic diseases who may face similar challenges and concerns.