Publicly Funded Family Planning Organizations' Response to the COVID-19 Pandemic in Texas.

INTRODUCTION: After the onset of the COVID-19 pandemic, the use of family planning services decreased, but there are limited data on how safety net providers were affected. METHODS: Between November 2020 and March 2021, we conducted in-depth interviews with administrators at health departments, federally qualified health centers, and specialized family planning organizations across Texas about pandemic-related changes in family planning services. We analyzed interview transcripts using an inductive thematic approach. RESULTS: Administrators at the 19 participating organizations described pervasive service disruptions. Some organizations closed for 6-8 weeks at the pandemic's onset owing to safety uncertainties and difficulty interpreting Texas' March 2020 executive order prohibiting "nonessential" medical services; others later suspended services after staff exposures. Health departments and federally qualified health centers commonly decreased family planning services to focus on COVID-19 response, leaving specialized family planning organizations to absorb displaced reproductive health care clients. Some of the advantages of service delivery modifications-including telehealth, curbside and drive-through prescription pickup, and medication by mail-were difficult to realize; barriers included low reimbursement, necessary patient examinations, and clients' confidentiality concerns and lack of technological resources. CONCLUSIONS: Texas' diverse network of family planning organizations illustrated a range of responses to the pandemic, and organizations often focused on their core missions-public health, primary care, or family planning.

Out-of-State Travel for Abortion among Texas Residents following an Executive Order Suspending In-State Services during the Coronavirus Pandemic.

During the COVID-19 pandemic, existing and new abortion restrictions constrained people's access to abortion care. We assessed Texas abortion patients' out-of-state travel patterns before and during implementation of a state executive order that prohibited most abortions for 30 days in 2020. We received data on Texans who obtained abortions between February and May 2020 at 25 facilities in six nearby states. We estimated weekly trends in the number of out-of-state abortions related to the order using segmented regression models. We compared the distribution of out-of-state abortions by county-level economic deprivation and distance traveled. The number of Texas out-of-state abortions increased 14% the week after (versus before) the order was implemented (incidence rate ratio [IRR] = 1.14; 95% CI: 0.49, 2.63), and increased weekly while the order remained in effect (IRR = 1.64; 95% CI: 1.23, 2.18). Residents of the most economically disadvantaged counties accounted for 52% and 12% of out-of-state abortions before and during the order, respectively (p < 0.001). Before the order, 38% of Texans traveled ≥250 miles one way, whereas during the order 81% traveled ≥250 miles (p < 0.001). Texans' long-distance travel for out-of-state abortion care and the socioeconomic composition of those less likely to travel reflect potential burdens imposed by future abortion bans.

Perceived Access to Contraception via Telemedicine Among Young Adults: Inequities by Food and Housing Insecurity.

BACKGROUND: Telemedicine expanded rapidly during the COVID-19 pandemic, including for contraceptive services. Data are needed to understand whether young people can access telemedicine for contraception, especially in underserved populations. OBJECTIVE: To compare young people's perceived access to telemedicine visits for contraception during the COVID-19 pandemic by food and housing insecurity. DESIGN: Supplementary study to a cluster randomized controlled trial in 25 community colleges in California and Texas. Online surveys were administered May 2020 to April 2021. Mixed-effects logistic regression models with random effects for site were used to examine differences in access to contraception through telemedicine by food and housing insecurity status, controlling for key sociodemographic characteristics, including race/ethnicity, non-English primary language, health insurance status, and state of residence, and contraceptive method used. PARTICIPANTS: 1,414 individuals assigned female at birth aged 18-28. MAIN MEASURES: Survey measures were used to capture how difficult it would be for a participant to have a telemedicine visit (phone or video) for contraception. KEY RESULTS: Twenty-nine percent of participants were food insecure, and 15% were housing insecure. Nearly a quarter (24%) stated that it would be difficult to have a phone or video visit for contraception. After accounting for sociodemographic factors and type of method used, food insecure (adjusted odds ratio [aOR], 2.17; 95% confidence interval [CI], 1.62-2.91) and housing insecure (aOR, 1.62; 95% CI, 1.13-2.33) participants were significantly more likely to report that it would be difficult to use telemedicine for contraception during the pandemic. CONCLUSIONS: Underserved patients are those who could benefit most from the expansion of telemedicine services, yet our findings show that young people experiencing basic needs insecurity perceive the greatest difficulty accessing these services for essential reproductive care. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03519685.

Seeking abortion care in Ohio and Texas during the COVID-19 pandemic.

OBJECTIVES: Political and public health responses to the COVID-19 pandemic changed provision of abortion care and exacerbated existing barriers. We aimed to explore experiences of individuals seeking abortion care in 2 abortion-restrictive states in the United States where state policies and practice changes disrupted abortion provision during the pandemic. STUDY DESIGN: We conducted 22 semistructured interviews in Texas (n = 10) and Ohio (n = 12) to assess how state executive orders limiting abortion, along with other public health guidance and pandemic-related service delivery changes, affected individuals seeking abortion care. We included individuals 18 years and older who contacted a facility for abortion care between March and November 2020. We coded and analyzed interview transcripts using both inductive and deductive approaches. RESULTS: Participants reported obstacles to obtaining their preferred timing and method of abortion. These obstacles placed greater demands on those seeking abortion and resulted in delays in obtaining care for as long as 11 weeks, as well as some being unable to obtain an abortion at all. CONCLUSIONS: Political and public health responses to the COVID-19 pandemic - exacerbated pre-pandemic barriers and existing restrictions and constrained options for people seeking abortion in Ohio and Texas. Delays were consequential for all participants, regardless of their ultimate ability to obtain an abortion. IMPLICATIONS: During the COVID-19 pandemic, state executive orders and clinic practices exacerbated already constrained access to care. Findings highlight the importance of protecting timely care and the full range of abortion methods. Findings also preview barriers individuals seeking abortion may encounter in states that restrict or ban abortion.

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

CONTEXT: The important role of Title X sites in supporting publicly funded reproductive healthcare was elevated during the COVID-19 pandemic, as many people experienced economic uncertainty and changed their fertility preferences. In this study, we assessed changes in service delivery during the first year of the COVID-19 pandemic at Title X-supported sites in Texas, a large state with a high uninsured rate and a diverse Title X network. METHODS: Using surveys of Title X-funded organizations in Texas from April and November 2020, we examined the percentage of organizations reporting service modifications. With administrative data on 507,947 client encounters between March 2019 and March 2021, we assessed change in client volume at the onset of the pandemic and evaluated the association between regional COVID-19 case rates and the provision of key Title X services. RESULTS: In April 2020, most organizations (78%) limited in-person operations while implementing telehealth (74%) and contactless contraception (67%). Network-wide encounter volume declined by 26% at pandemic onset (incidence rate ratio [IRR] = 0.74, 95% confidence interval [CI] = 0.65, 0.84). Health departments experienced the steepest declines in encounter volume (IRR = 0.43, 95% CI = 0.36-0.50). Weekly encounters, particularly for long-acting reversible method placement/removal and sexually transmitted infection testing, decreased as COVID-19 rates increased. CONCLUSIONS: Investment in public health infrastructure, including providing robust support to health departments as well as rebuilding and expanding the Title X network, is essential to safeguarding access to publicly funded reproductive healthcare during and after the pandemic.

Minors' Experiences Accessing Confidential Contraception in Texas.

PURPOSE: Texas is one of 24 states that restricts minors' ability to obtain contraception without parental consent, unless they access confidential services at federally funded Title X clinics. This study explores Texas minors' reasons for and experiences seeking confidential contraception. METHODS: Between September 2020 and June 2021, we conducted in-depth phone interviews with 28 minors aged 15-17 years. Participants were recruited via the text line and Instagram account of an organization that helps young people navigate Texas' parental consent laws. Interview transcripts were coded and analyzed using inductive and deductive codes in our thematic analysis. RESULTS: Participants wanted to be proactive about preventing pregnancy by using more effective contraceptive methods but faced resistance from adults when they initiated conversations about sex and contraception or tried to obtain consent. In the absence of adult support, they turned to online and social media resources for information about types of contraception but encountered challenges finding accurate information about where to obtain methods in Texas without a parent. Only 10 participants were able to attend an appointment for contraception. Parents' increased monitoring of minors' activities during the COVID-19 pandemic, combined with transportation and appointment-scheduling barriers, made it difficult for minors to attend in-person visits, particularly if clinics were farther away. DISCUSSION: Minors in Texas faced a range of barriers to finding accurate information and obtaining confidential contraceptive services, which were exacerbated by the COVID-19 pandemic. Expanding options for accessible confidential contraception, along with repealing parental consent laws, would better support minors' reproductive autonomy.

Seeking abortion care in Ohio and Texas during the COVID-19 pandemic

Objectives Political and public health responses to the COVID-19 pandemic changed provision of abortion care and exacerbated existing barriers. We aimed to explore experiences of individuals seeking abortion care in two abortion-restrictive states in the United States where state policies and practice changes disrupted abortion provision during the pandemic. Study design We conducted 22 semi-structured interviews in Texas (n=10) and Ohio (n=12) to assess how state executive orders limiting abortion, along with other public health guidance and pandemic-related service delivery changes, affected individuals seeking abortion care. We included individuals 18 years and older who contacted a facility for abortion care between March and November 2020. We coded and analyzed interview transcripts using both inductive and deductive approaches. Results Participants reported obstacles to obtaining their preferred timing and method of abortion. These obstacles placed greater demands on those seeking abortion and resulted in delays in obtaining care for as long as 11 weeks, as well as some being unable to obtain an abortion at all. Conclusions Political and public health responses to the COVID-19 pandemic exacerbated pre-pandemic exacerbated pre-pandemic barriers and existing restrictions and constrained options for people seeking abortion in Ohio and Texas. Delays were consequential for all participants, regardless of their ultimate ability to obtain an abortion.

Geographic disparities in disruptions to abortion care in Louisiana at the onset of the COVID-19 pandemic.

OBJECTIVES: Prior research identified a significant decline in the number of abortions in Louisiana at the onset of the COVID-19 pandemic, as well as increases in second-trimester abortions and decreases in medication abortions. This study examines how service disruptions in particular areas of the state disparately affected access to abortion care based on geography. STUDY DESIGN: We collected monthly service data from Louisiana's abortion clinics (January 2018-May 2020) and conducted mystery client calls to determine whether clinics were scheduling appointments at pandemic onset (April-May 2020). We used segmented regression to assess whether service disruptions modified the main pandemic effects on the number, timing, and type of abortions using stratified models and interaction terms. Additionally, we calculated the median distance that Louisiana residents traveled to the clinic where they obtained care. RESULTS: For residents whose closest clinic was consistently scheduling appointments at the onset of the pandemic, the number of monthly abortions did not change (IRR = 1.07, 95% CI: 0.84-1.36). For those whose closest clinic services were disrupted, the number of monthly abortions decreased by 46% (IRR = 0.54, 95% CI: 0.45-0.65). Similarly, increases in second-trimester abortions and decreases in medication abortions were concentrated in areas where residents experienced service disruptions (AOR = 2.25, 95% CI: 1.21-4.56 and AOR = 0.59, 95% CI: 0.29-0.87, respectively) and were not seen elsewhere in the state. CONCLUSION: Changes in the number, timing and type of abortions were concentrated among residents in particular areas of Louisiana. The early stages of the COVID-19 pandemic exacerbated geographic disparities in access to abortion care. IMPLICATIONS: Disruptions in services at the beginning of the COVID-19 pandemic in Louisiana meaningfully affected pregnant people's ability to obtain an abortion at their nearest clinic. These findings reinforce the importance of developing mechanisms to support pregnant people during emergency situations when traveling to a nearby clinic is no longer possible.

Accuracy of self-assessment of gestational duration among people seeking abortion.

BACKGROUND: Mifepristone, used together with misoprostol, is approved by the United States Food and Drug Administration for medication abortion through 10 weeks' gestation. Although in-person ultrasound is frequently used to establish medication abortion eligibility, previous research demonstrates that people seeking abortion early in pregnancy can accurately self-assess gestational duration using the date of their last menstrual period. OBJECTIVE: In this study, we establish the screening performance of a broader set of questions for self-assessment of gestational duration among a sample of people seeking abortion at a wide range of gestations. STUDY DESIGN: We surveyed patients seeking abortion at 7 facilities before ultrasound and compared self-assessments of gestational duration using 11 pregnancy dating questions with measurements on ultrasound. For individual pregnancy dating questions and combined questions, we established screening performance focusing on metrics of diagnostic accuracy, defined as the area under the receiver operating characteristic curve, sensitivity (or the proportion of ineligible participants who correctly screened as ineligible for medication abortion), and proportion of false negatives (ie, the proportion of all participants who erroneously screened as eligible for medication abortion). We tested for differences in sensitivity across individual and combined questions using McNemar's test, and for differences in accuracy using the area under the receiver operating curve and Sidak adjusted P values. RESULTS: One-quarter (25%) of 1089 participants had a gestational duration of >70 days on ultrasound. Using the date of last menstrual period alone demonstrated 83.5% sensitivity (95% confidence interval, 78.4-87.9) in identifying participants with gestational durations of >70 days on ultrasound, with an area under the receiver operating characteristic curve of 0.82 (95% confidence interval, 0.79-0.85) and a proportion of false negatives of 4.0%. A composite measure of responses to questions on number of weeks pregnant, date of last menstrual period, and date they got pregnant demonstrated 89.1% sensitivity (95% confidence interval, 84.7-92.6) and an area under the receiver operating curve of 0.86 (95% confidence interval, 0.83-0.88), with 2.7% of false negatives. A simpler question set focused on being >10 weeks or >2 months pregnant or having missed 2 or more periods had comparable sensitivity (90.7%; 95% confidence interval, 86.6-93.9) and proportion of false negatives (2.3%), but with a slightly lower area under the receiver operating curve (0.82; 95% confidence interval, 0.79-0.84). CONCLUSION: In a sample representative of people seeking abortion nationally, broadening the screening questions for assessing gestational duration beyond the date of the last menstrual period resulted in improved accuracy and sensitivity of self-assessment at the 70-day threshold for medication abortion. Ultrasound assessment for medication abortion may not be necessary, especially when requiring ultrasound could increase COVID-19 risk or healthcare costs, restrict access, or limit patient choice.

Disruptions to Abortion Care in Louisiana During Early Months of the COVID-19 Pandemic.

Objectives. To examine changes in abortions in Louisiana before and after the COVID-19 pandemic onset and assess whether variations in abortion service availability during this time might explain observed changes. Methods. We collected monthly service data from abortion clinics in Louisiana and neighboring states among Louisiana residents (January 2018‒May 2020) and assessed changes in abortions following pandemic onset. We conducted mystery client calls to 30 abortion clinics in Louisiana and neighboring states (April‒July 2020) and examined the percentage of open and scheduling clinics and median waits. Results. The number of abortions per month among Louisiana residents in Louisiana clinics decreased 31% (incidence rate ratio = 0.69; 95% confidence interval [CI] = 0.59, 0.79) from before to after pandemic onset, while the odds of having a second-trimester abortion increased (adjusted odds ratio [AOR] = 1.91; 95% CI = 1.10, 3.33). The decrease was not offset by an increase in out-of-state abortions. In Louisiana, only 1 or 2 (of 3) clinics were open (with a median wait > 2 weeks) through early May. Conclusions. The COVID-19 pandemic onset was associated with a significant decrease in the number of abortions and increase in the proportion of abortions provided in the second trimester among Louisiana residents. These changes followed service disruptions.

Improving assessment of demand for postpartum tubal ligation among publicly insured women in Texas.

OBJECTIVE: To assess an alternative method for estimating demand for postpartum tubal ligation and evaluate reproductive trajectories of low-income women who did not obtain a desired procedure. STUDY DESIGN: In a 2-year cohort study of 1700 publicly insured women who delivered at 8 hospitals in Texas, we identified those who had an unmet demand for tubal ligation prior to discharge from the hospital. We classified unmet demand as explicit or prompted based on survey questions that included a prompt regarding whether the respondent would like to have had a tubal ligation at the time of delivery. We assessed persistence of demand for permanent contraception, contraceptive use, and repeat pregnancies among all study participants who wanted but did not get a postpartum procedure. RESULTS: Some 426 women desired a postpartum tubal ligation; 219 (51%) obtained one prior to discharge. Among the 207 participants with unmet demand, 62 (30%) expressed an explicit preference for the procedure, while 145 (70%) were identified from the prompt. Most with unmet demand still wanted permanent contraception 3 months after delivery (156/184), but only 23 had obtained interval procedures. By 18 months, the probability of a woman with unmet demand conceiving a pregnancy that she would likely carry to term was 12.5% (95% CI: 8.3%-18.5%). CONCLUSIONS: The majority of unmet demand for postpartum tubal ligation among publicly insured women in Texas was uncovered via a prompt and would not have been evident in clinical records or from consent forms. Women unable to obtain a desired procedure had a substantial chance of pregnancy within 18 months after delivery. IMPLICATIONS: Estimates of unmet demand for postpartum tubal ligation based on clinical records and consent forms likely underestimate desire for permanent contraception. Among low-income women in Texas, those with unmet demand for postpartum tubal ligation require improved access to effective contraception.