bluuebunny/crossref_metadata_2025_split huggingface dataset:
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.
The Clinical Importance of Postpartum Contraception Upon Hospital Discharge [25J]
Authors: Nguyen Ha Vi , Pan Yangshu , Burke Anne E. 
Published: April 2020

INTRODUCTION:
The immediate postpartum period is critical for contraceptive provision due to rapid fertility return but only half of women attend the postpartum visit. Our objective was to examine whether immediate postpartum contraception influenced the likelihood of postpartum follow-up or subsequent pregnancies within 3-years of delivery.

METHODS:
The IRB approval was obtained. We conducted a retrospective chart review of hospital deliveries from April–July 2015 and reviewed follow-up data through 2018. The primary outcome was immediate postpartum contraception (provided before discharge). Secondary outcomes were postpartum visit attendance, follow-up after postpartum visit, and subsequent pregnancies. Chi-square analysis was used for between-group comparisons.

RESULTS:
Among 307 patients, the largest percentage (n=76, 24.8%) received contraceptive implants. Only 44.3% (n=133) of women returned for the postpartum visit; there were no differences by contraceptive method. There were 171 (55.7%) women without follow-up past the postpartum period. Patients who received LARC or permanent contraception immediately postpartum were less likely to follow up after the postpartum visit (n=52, 38.2%) compared to less effective methods (n=84, 61.8%; P<.05). Of 55 women with subsequent pregnancies, 13 (23.6%) had been discharged with LARC, and 42 (76.4%) with less effective methods or no method (P<.001).

CONCLUSION:
Less than half of patients returned for postpartum care. Women discharged with LARC or permanent methods were less likely to have follow-up after the postpartum visit, or have subsequent pregnancies within a 3-year time frame compared to women discharged with less effective or no contraception. Results highlight the importance of offering contraception in the immediate postpartum period.
The Effects of Postpartum Long-Acting Reversible Contraceptive Insertion From the Medicaid Payer Perspective [26J]
Authors: Swiatlo Alison , Miele Kathryn , Morse Jessica E. , Lich Kristen , Krashin Jamie 
Published: April 2020

INTRODUCTION:
This Markov model was created to determine the difference in unintended pregnancies, costs, and cost effectiveness with immediate versus standard placement of postpartum long-acting reversible contraception (ppLARC), which includes intrauterine devices (IUDs) and implants.

METHODS:
This Markov model examines a theoretical cohort of 1,000 women whose obstetrical care was paid for by North Carolina Medicaid and who requested ppLARC prior to discharge from their delivery hospitalization from the perspective of NC Medicaid. Probability inputs came from the literature and cost inputs are from NC Medicaid fee schedules. Markov cycles were weekly with an 18 month time horizon. During the time horizon postpartum, a woman could continue with her current contraceptive method, change to a different method, or become pregnant. Pregnancy is an absorbing state with five different outcomes. Probabilistic sensitivity analyses were conducted on key model parameters.

RESULTS:
Immediate ppLARC would result in 182 fewer unintended pregnancies and save North Carolina $624,372 over two years. Immediate ppLARC was cost saving, with an ICER of $3,435 saved per unintended pregnancy prevented. In sensitivity analyses, immediate ppLARC remained cost saving except when parameters were varied widely from expected values.

CONCLUSION:
Immediate post-partum insertion of long-acting reversible contraceptives was found to be associated with cost-savings and fewer unintended pregnancies.
The Impact of Medicaid Reimbursement on Rates of Postpartum LARC Uptake [27J]
Authors: Addante Amy , Koch Susannah , Brubaker Allison , Hillary Duckham , Tepe Melissa , Carter Ebony 
Published: April 2020

INTRODUCTION:
There are many barriers to immediate postpartum long acting reversible contraception (LARC) placement, including lack of knowledge, restrictive placement criteria, inadequate reimbursement, and policies banning reimbursement for placement during an inpatient hospitalization. We aimed to determine the impact of a policy change by Missouri Medicaid in October of 2016 allowing reimbursement of immediate postpartum LARC placement.

METHODS:
We completed a retrospective cohort study comparing patients who delivered at Barnes Jewish Hospital (BJH) one year before (September, 2015-September 2016) and after (November, 2016-November, 2017) the Medicaid LARC immediate postpartum reimbursement policy change. Patients who had a contraindication to LARC placement were excluded. The primary outcome was immediate postpartum LARC placement. Demographic characteristics were compared using chi-square and Fisher’s exact test, as appropriate. Pertinent confounders were controlled for using logistic regression and the analysis was stratified by insurance type.

RESULTS:
A total of 6,233 women were included with 3,105 delivering before the postpartum LARC policy change and 3,128 delivering after. Immediate postpartum LARC uptake increased from 0.5% (n=16) to 7.3% (n=229) after the policy change (adjusted odds ratio (aOR) 15.4; 95% CI 9.3-25.8). In stratified analysis, postpartum LARC uptake increased in both women enrolled in Medicaid (0.7% to 9.6%; aOR 14.8; 95% CI 8.6-25.9) and private insurance (0.2% to 2.9%; aOR 13.3; 95% CI 3.2-55.9).

CONCLUSION:
Medicaid reimbursement for inpatient postpartum LARC is associated with an increased uptake among women with both Medicaid and private insurance. This policy change is an important step in reducing the burden of unintended pregnancies.
Complications of Dilation and Evacuation and Induction of Labor for Second-Trimester Fetal Demise [31J]
Authors: McLaren Hillary , Cancino Dominic , McCulloch Megan , Fitzgerald Sharon , French Valerie 
Published: April 2020

INTRODUCTION:
We compared the frequency of complications for dilation and evacuation (D&E) and induction of labor (IOL) for treatment of second-trimester intrauterine fetal demise (IUFD).

METHODS:
We performed a retrospective cohort study of women with an IUFD between 14-24 weeks who underwent D&E or IOL at a university hospital between June 2009 and June 2019. We defined complications a priori as: 1) infection, 2) uterine atony, 3) retained products of conception, 4) hemorrhage, 5) uterine perforation (D&E only), 6) uterine aspiration (IOL only), 7) cervical laceration (D&E only), 8) uterine rupture, 9) unplanned admission, 10) readmission within 14 days, 11) blood transfusion, 12) intensive care unit admission, 13) removal or injury to an organ, 14) uterine rupture, 15) cardiopulmonary arrest, 16) any other unplanned surgery, and 17) death. We also assessed a composite of major complications, defined as complications 8-17. We assessed differences in composite complication frequency with chi-squared and Fisher’s exact tests.

RESULTS:
Of the 119 women who met inclusion criteria, 41 underwent D&E and 78 underwent IOL. In our preliminary analysis, 29.2% (12/41) women in the D&E group and 24.4% (19/78) in the IOL group (P=.56) experienced any complication. No women in the D&E group experienced a major complication and 3 women in the IOL group experienced a major complication (3.8%, P=.55).

CONCLUSION:
D&E and IOL had comparable complication rates for women in our study. Patients should be offered both options in the treatment of a second-trimester IUFD.
Influenza and Tdap Vaccines: Practices and Perception Among Hispanic Women Attending Tertiary Center in Puerto Rico [32J]
Authors: Miranda Angela , Vargas Darlene , Medina Yailis 
Published: April 2020

INTRODUCTION:
Explore influenza and Tdap immunization knowledge, attitudes, and practices among Hispanics patients attending prenatal care in a tertiary hospital in Puerto Rico as well as barriers encountered by patients regarding vaccination practices during pregnancy.

METHODS:
Descriptive study conducted at Adult District Hospital prenatal care clinics in the Medical Sciences Campus of Puerto Rico from September 2016 to June 2017.

RESULTS:
A total of 189 were recruited. Regarding Influenza vaccine: 75.6% were offered or oriented about Influenza vaccination, 51.8% had received the vaccine at least once (only 12.2% during current pregnancy) and, 57.1% reported receiving information about influenza infection risks in pregnancy, mainly from health care professionals and media. For Tdap only 20.6% of women were offered or oriented about the vaccine and 23.3% received the vaccine. 55.6% of patient had not been oriented about potential dangers of the pertussis infection; for the few oriented, health professionals were their predominant source. In terms of barriers, lack of information about vaccination and the effects/benefits during pregnancy were the most frequent.

CONCLUSION:
Our study identifies the existing gap of information regarding Influenza and Tdap vaccine. Physicians play a pivotal role in preventive care and new strategies are needed to optimize education to our patients.
Is Screening Positive for Sleep Apnea Associated With a Higher Rate of Miscarriage? [33J]
Authors: Larson Jeannette M. , Bazalakova Mihaela H. , DelBeccaro Melanie , Aagaard Kjersti , Antony Kathleen M. 
Published: April 2020

INTRODUCTION:
The purpose of this study was to evaluate whether positive questionnaire-based screening for obstructive sleep apnea (OSA) was associated with higher rates of miscarriage (SAB).

METHODS:
Secondary analysis of a prospective observational study of participants enrolled in an OSA screening study between 2010–2012. This analysis received an IRB exemption. A screening questionnaire with standard Epworth (ESS), Berlin (BQ), and novel items was administered at a prenatal care visit. The results of women who completed the survey in the first trimester (1T) were assessed for association with SAB.

RESULTS:
In a cohort of 213 women screened in the 1T, 30% (n=64) had elevated BQ or ESS scores, 18.8% (n=40) had high ESS scores and 14.6% (n=31) had elevated BQ scores suggestive of risk of OSA. 3.29% (n=7) had high ESS and BQ scores. Women who had both elevated ESS and BQ scores were more likely to experience SAB than those who had elevated scores on one or neither (P=.018). Women who reported snoring (P=.042) or hypertension (P=.013) in the 1T were more likely to experience SAB than women who did not. In contrast, women who reported napping in the 1T were less likely to experience SAB than women who did not (P=.045).

CONCLUSION:
Elevated BQ and ESS scores are statistically significantly associated with SAB. Snoring, naps and hypertension were the only individual questions from the BQ and ESS with statistically significant associations with SAB. Further investigation into this topic is warranted.