Ease of removal of malpositioned intrauterine devices: A retrospective cohort study.

OBJECTIVE: This study aimed to compare removal timing, techniques, and success of malpositioned intrauterine device (IUDs) to nonmalpositioned IUDs. STUDY DESIGN: We performed a retrospective cohort study of IUD users with ultrasound performed between July 2014 and July 2017 within one medical system. We used Fisher exact and Wilcoxon rank-sum tests to compare clinical characteristics and IUD removal details between patients with malpositioned and nonmalpositioned IUDs. RESULTS: Of 1759 ultrasounds reporting the presence of an IUD, 436 described IUD malposition. Of these, 150 described the IUD as embedded and 16 as partially perforated. IUDs were more likely to be removed and removed sooner for patients with malpositioned compared with nonmalpositioned IUDs (281/436 vs 545/1323, p < 0.001 and median 17 days vs 236 days from the index ultrasound, p < 0.001). Most IUDs, malpositioned and nonmalpositioned, were removed on the first attempt (82%, 85%), by a generalist obstetrician and gynecologist (75%, 70%), using a ring forceps (73%, 65%). Most embedded and partially perforated IUDs were removed (68%, 69%), using a ring forceps (59%, 67%), on the first attempt (84%, 91%). CONCLUSIONS: Malpositioned IUDs were more likely to be removed and removed sooner than nonmalpositioned IUDs. Most IUDs, even IUDs labeled as partially perforated or embedded, were removed by a generalist obstetrician and gynecologist, using ring forceps, on first attempt. IMPLICATIONS: Ultrasound findings of IUD malposition are not associated with difficult IUD removal.

Consensus on Social Determinants of Health Knowledge Topics and Behavior Learning Goals Across Primary Care Residencies: Results of a Delphi Study.

PURPOSE: Social determinants of health (SDH) are a substantial contributor to health outcomes and health inequities across populations. The Accreditation Council for Graduate Medical Education has called for the incorporation of SDH into graduate medical education (GME), yet there is no consensus on what SDH knowledge or skills residents in primary care specialties should have on completion of training. The aim of this study was to develop expert consensus on the most important SDH knowledge topics and behavior learning goals for residents in 4 primary care fields. METHOD: The authors used a modified Delphi technique to develop consensus among experts in internal medicine, pediatrics, family medicine, and obstetrics and gynecology across the United States via a survey administered between February and October 2021. They conducted a literature review on SDH in GME to develop an initial set of topics and learning goals and recruited experts who published about SDH and GME or led an SDH curriculum in GME. Consensus was determined a priori as 80% agreement that a topic or learning goal was very or extremely important. RESULTS: Forty-one experts participated in the first round of the survey and 33 participated in the second round (80% retention). Experts reached consensus on the importance of 22/51 (43%) topics and 18/47 (38%) learning goals. Topics reaching consensus emphasized structural forces, broad domains of SDH, resources for addressing SDH, and advocacy strategies and resources. Learning goals reaching consensus focused on individual- and interpersonal-level behaviors. CONCLUSIONS: To the authors' knowledge, this study represents the first rigorous evaluation of expert consensus on SDH in GME across 4 primary care specialties. The results could inform curriculum development and implementation and program evaluation, residency program goals, and shared GME milestones. Among other things, future studies can assess expert consensus on SDH in GME across nonprimary care specialties.

Protecting reproductive health information in the post-Roe era: interoperability strategies for healthcare institutions.

On June 24, 2022, the US Supreme Court ended constitutional protections for abortion, resulting in wide variability in access from severe restrictions in many states and fewer restrictions in others. Healthcare institutions capture information about patients' pregnancy and abortion care and, due to interoperability, may share it in ways that expose their providers and patients to social stigma and potential legal jeopardy in states with severe restrictions. In this article, we describe sources of risk to patients and providers that arise from interoperability and specify actions that institutions can take to reduce that risk. Institutions have significant power to define their practices for how and where care is documented, how patients are identified, where data are sent or hosted, and how patients are counseled, and thus should protect patients' privacy and ability to receive medical care that is safe and legal where it is performed.

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

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

Telemedicine for Contraceptive Counseling During the COVID-19 Pandemic: Referral Patterns and Attendance at Follow-Up Visits.

Objective: To describe referral patterns and attendance at follow-up visits for patients who received contraceptive counseling via telemedicine during the COVID-19 pandemic. Study Design: This is a prospective study of patients seen remotely during the early phase of the COVID-19 pandemic in New York City. We tracked referral rates, referral reasons, in-person visit show rates, and additional visits. We also administered a patient survey at 6 months. Using Stata SE 16, we conducted a multivariable modified Poisson regression with robust error variances to examine the predictors of attending an in-person visit within 30 days. Results: We included 169 patients who had visits between April 1 and June 30, 2020. Of these, 109 (64.5%) were referred for in-person visits, and 83 (76.1%) of those referred attended within 30 days. The most common reasons for referral were long-acting reversible contraception (LARC) removal and insertion. The relative risk (RR) of attending a visit within 30 days of referral was 24% higher for those referred for LARC removal compared with those referred for other reasons (RR 1.24, 95% confidence interval [CI] 1.08-1.69), and it was 29% lower for those aged 18-25 compared with those in the reference age (26-35) group (RR 0.71, 95% CI 0.51-0.98). At 6 months, 69.4% of patients were still using the method they decided on at the telemedicine visit, and 44.4% would choose telemedicine for their next contraception visit. Conclusions: Approximately one third of patients seeking contraceptive counseling via telemedicine did not seek additional in-person visits over a 6-month period. Among the patients referred for in-person visits, referral reason and patient age may impact attendance rates.

Attitudes and experiences with termination of pregnancy among Irish obstetrics & gynaecology trainees in the context of recent legal change: A survey study.

OBJECTIVE: This study examines Irish obstetrics and gynaecology trainees' experiences with and opinions of termination of pregnancy (ToP) after legal change. STUDY DESIGN: We invited obstetrics & gynaecology non-consultant hospital doctors (NCHDs) to participate in a web-based survey through a professional e-mail listserv. We conducted descriptive statistical analyses of responses using Stata SE Version 16. RESULTS: A total of 102/202 (50.5%) trainees responded to the survey. Of these, 61.8% believed that ToP should be allowed on request up to 12 weeks and in limited circumstances thereafter (in line with current law), and 19.6% believe ToP should be allowed on request even after 12 weeks. Knowledge about the abortion law was high (70.6% achieved a perfect knowledge score). Since the new law came into effect, 61.8% of trainees reported participation in abortion care, though only 25.5% had performed surgical procedures. More than 75% of respondents would like to receive more training in all clinical skills related to ToP. In the future, 67.6% of respondents would be willing to provide TOP in all circumstances allowed by law. CONCLUSION: Irish obstetrics & gynaecology NCHDs are generally supportive of the legislation. Few trainees have performed surgical abortions, and most would like to receive additional clinical training related to ToP.

Telemedicine for contraceptive counseling: Patient experiences during the early phase of the COVID-19 pandemic in New York City.

OBJECTIVE: During theCOVID-19 pandemic, many clinicians increased provision of telemedicine services. This study describes patient experiences with telemedicine for contraceptive counseling during the COVID-19 pandemic in New York City. STUDY DESIGN: This is a mixed-methods study which includes a web-based or phone survey and in-depth phone interviews with patients who had telemedicine visits for contraception. RESULTS: A total of 169 patients had eligible telemedicine visits between April 1 and June 30, 2020. Of these, 86 (51%) responded to the survey, and 23 (14%) participated in the interviews. We found that 86% of survey respondents were very satisfied with the telemedicine visit, and 63% said it completely met their needs. A majority (73%) strongly agreed that these visits should be maintained after the COVID-19 pandemic, and half (51%) would be very likely to choose them over in-person visits. In-depth interviews highlighted the convenience of telemedicine, especially for those with work or parenting responsibilities. Although some patients had in-person visits after telehealth, many appreciated the counseling they received remotely, and found the subsequent in-person visits more efficient. Patients identified visits that do not require physical exams as ideal visits for telehealth, and some hoped that all or most of their future visits would be telehealth visits. Many patients (43%) expressed a preference for phone over video visits. CONCLUSIONS: Patients reported an overall positive experience with telemedicine visits for contraceptive counseling during the COVID-19 pandemic. They appreciated the convenience of telemedicine visits and valued the virtual counseling experience. IMPLICATIONS: Health care providers who initiated or expanded telemedicine services for contraceptive counseling during the COVID-19 pandemic should consider continuing to offer them after the pandemic. At the policy level, these findings favor expanding access to telemedicine and providing reimbursement for virtual visits, including telephone visits.

Abortion attitudes, training, and experience among medical students in Jamaica, West Indies.

OBJECTIVE: To define abortion attitudes, training and experience among medical students in Jamaica, a restricted environment for legal abortion. METHOD: From September to November 2017 we conducted an anonymous online cross-sectional survey among medical students enrolled at the University of West Indies (UWI) in Jamaica. An abortion attitudes sum score was used for analysis. Multivariate regression was applied to evaluate the impact of characteristics and experiences on abortion attitudes. RESULTS: The primary outcome was a validated composite abortion attitudes sum score, ranging from zero to forty-five. 1404 students completed the survey for a response rate of 88%. 64% had a positive attitude towards abortion. In multivariate analysis, medical students' attitudes were favorably impacted by a prior personal or family experience with abortion, identifying as non-religious, being older in age and mixed raced. 1321 (94%) agreed that abortion training should be included in the medical school curriculum. 78.8% reported no abortion training and only 17.9% reported miscarriage management training. CONCLUSION: Medical students at UWI had favorable attitudes towards abortion, despite their limited training in a restrictive environment. Prior personal experience with abortion and being non-religious were the strongest predictor of favorable attitudes. Increased training and clinical exposure may prove to be crucial in improving access of safe abortion.

The impact of menstrual hygiene management on adolescent health: The effect of Go! pads on rate of urinary tract infection in adolescent females in Kibogora, Rwanda.

OBJECTIVE: To determine the rates of urinary tract infection (UTI) in adolescent users of menstrual pads versus non-users in a rural area of Rwanda. METHODS: An interventional prospective cohort study was conducted at four secondary schools in the Western Province of Rwanda from May 12, 2017 to October 20, 2017. Inclusion criteria were female students aged 18-24 who were menstruating and volunteered to participate in the study. In total, 240 adolescent participants were assigned to two cohorts; 120 received menstrual pads for 6 months and the other 120 did not use pads. Baseline symptoms and urine cultures were obtained. Symptoms and methods of menstrual hygiene management were assessed and urine cultures were obtained every 2 months. The primary outcome was the presence of UTI diagnosed by positive urine culture. Secondary outcomes were symptoms of UTI, vulvovaginal symptoms, sexual activity, dyspareunia, and self-reported sexually transmitted infection. Generalized estimating equations with nesting were used to assess associations of pad use with study outcomes. RESULTS: A total of 209 participants completed the study. There was no difference in rates of positive urine culture. A decreased odds of vulvovaginal symptoms was found in self-reported "always" versus "never" pad users (odds ratio [OR] 0.64, 95% confidence interval [CI] 0.43-0.96; P=0.031). CONCLUSIONS: Despite not finding any difference in rates of UTI, the present study showed a decreased rate of vulvovaginal symptoms in users of menstrual pads. Further research investigating rates of genital infections in this population is thus necessary.

Exposure to routine availability of immediate postpartum LARC: effect on attitudes and practices of labor and delivery and postpartum nurses.

OBJECTIVES: Nurses play an integral role in intrapartum and postpartum patient education. This exploratory study aims to assess the attitudes, knowledge, and practices of labor and delivery and postpartum nurses regarding contraception and evaluate for changes in these measures 1 year after an institutional initiative allowing routine availability of immediate postpartum long-acting reversible contraception (LARC). STUDY DESIGN: In 2014, Montefiore Medical Center began to routinely offer comprehensive immediate postpartum contraception. The initiative included education and feedback sessions for labor and delivery and postpartum nurses on contraception, including immediate postpartum initiation of LARC. Nurses completed anonymous surveys at the beginning of the initiative (n=59) and at 1 year (n=56). We compared baseline and 1 year survey results of contraceptive knowledge, attitudes and practices using χ2 test, Fisher's Exact Test, or t test as appropriate. RESULTS: Nurses who stated they counseled patients on contraception "always" or "most of the time" increased from 27/59 (46%) to 40/56 (71%) (p=.005). The number of nurses who would recommend the intrauterine device and implant for postpartum contraception increased from 1/59 (2%) to 18/56 (32%) (p<.0001). Attitudes towards injectable contraception and breastfeeding remained negative; 27/59 nurses (46%) at baseline and 34/56 (61%) at 1 year agreed with the statement "DMPA [depot medroxyprogesterone acetate] has a negative effect on breastfeeding." CONCLUSIONS: Experience working in a location with routine access to immediate postpartum contraception is associated with increased awareness among nurses of postpartum contraceptive options, especially LARC, and increased contraceptive counseling. Concerns about the impact of hormonal contraception on breastfeeding, specifically DMPA, are persistent and prevalent. IMPLICATIONS: Labor and delivery and postpartum nurses' knowledge regarding immediate postpartum contraception, particularly LARC methods, may change with exposure to routine access to these methods. This exposure may also impact nurses' practices of providing patient counseling on what methods are appropriate for postpartum women.

A data extraction algorithm for assessment of contraceptive counseling and provision.

BACKGROUND: Contraception counseling and provision is an essential preventative service. Real-time assessment of these services is critical for quality improvement and comparative study. Direct observation is not feasible on a large scale, so indirect measures (such as chart review) have been determined to be acceptable tools for this assessment. Computer-aided chart review has significant benefits over manual chart review as far as greater efficiency and ease of repeated measurements. The wide use of electronic medical records provides an opportunity to create a data extraction algorithm for computer-aided chart review that is sharable among institutions. We provide a useful schema for others who use electronic medical record systems and are interested in real-time assessment of contraception counseling and provision for the purposes of baseline assessment of services and quality improvement. OBJECTIVE: The purpose of this study was to create a comprehensive and accurate data extraction algorithm that is useful in the assessment of contraception counseling and provision rates in the outpatient setting. STUDY DESIGN: We included all visits between August 2015 and May 2016 at 8 outpatient clinics that are affiliated with a large, urban academic medical center in which nonpregnant women who were 14-45 years old were seen by a nurse practitioner, physician's assistant, or physician. Contraception-related prescriptions, International Classification of Diseases codes, current procedural terminology codes, and search-term capture were extracted with the use of structured query language from electronic medical record data that were stored in a relational database. The algorithm's hierarchy was designed to query prescription data first, followed by International Classification of Diseases and current procedural terminology codes, and finally search-term capture. Visits were censored when the first positive evidence of contraceptive service was obtained. Search terms were selected based on group discussion of investigators and providers. This algorithm was then compared with manual chart review and refined 3 times until high sensitivity and specificity, when compared with manual chart review, were achieved. RESULTS: There were 22,134 visits of reproductive-aged women who our inclusion criteria. Electronic medical record evidence of contraception counseling or provision was found in 56.9% of these visits. Of these, 21.3% were captured by prescriptions; 8.9% were captured by International Classification of Diseases codes, and 69.7% were captured by search-term capture with the use of our algorithm. Among visits with evidence of contraception counseling without provision, 15.7% were captured by diagnosis codes and 84.3% were captured by search-term capture. When compared with manual chart review, sensitivity and specificity improved from 0.79 and 0.85 to 0.99 and 0.98, respectively, over the 3 rounds of testing and revision. CONCLUSION: Data extraction algorithms can be used effectively for computer-aided chart review of contraception counseling and provision measures, but testing and refinement are extremely important. Search-term capture from unstructured data is a critical component of a comprehensive algorithm, especially for the capture of instances of contraception counseling without provision. The algorithm that we developed here could be used by others with an electronic medical record system who are interested in real-time assessment, quality improvement, and comparative study of the delivery of contraceptive services. The ease of execution of this algorithm also allows for its repeated use for ongoing assessments over time.

From Pill to Condom, or Nothing at all: HIV Diagnosis and Discontinuation of Highly Effective Contraceptives Among Women in Northeast Brazil.

This is a cross-sectional study examining highly effective contraceptive (HEC) use among HIV-positive women in Salvador, Brazil. We used multivariate logistic regression to look for predictors of alternative contraceptive choices among women who discontinued HEC after HIV diagnosis. Of 914 participants surveyed, 38.5% of participants used HEC before but not after diagnosis. Of these, 65.9% used condoms alone; 19.3% used no protection; and 14.8% reported abstinence. Use of condoms alone was associated with a history of other sexually transmitted infections (AOR 2.18, 95% CI 1.09-4.66, p = 0.029). Abstinence was associated with recent diagnosis (AOR 8.48, 95% CI 2.20-32.64, p = 0.002). Using no method was associated with age below 25 (AOR 5.13, 95% CI 1.46-18.00, p = 0.011); income below minimum wage (AOR 2.54, 95% CI 1.31-4.92, p = 0.006); HIV-positive partner status (AOR 2.69, 95% CI 1.03-7.02, p = 0.043); and unknown partner status (AOR 2.90, 95% CI 1.04-8.05, p = 0.042). Improved contraceptive counseling is needed after HIV diagnosis. Continuation of HEC should be encouraged for women wishing to prevent pregnancy, and may increase contraceptive coverage among HIV-positive women.

Family planning knowledge and use among women in camps for internally displaced people in the Democratic Republic of the Congo.

OBJECTIVE: To describe family planning awareness and needs among internally displaced women residing in the Mugunga camps in North Kivu, eastern Democratic Republic of the Congo. METHODS: A cross-sectional survey of women aged 14-45 years residing in the Mugunga camps was conducted during March 2014. The verbally administered survey assessed participants' obstetric history and their family planning knowledge, interest, and use. Descriptive statistics were obtained. RESULTS: Of the 155 participants, 145 (93.5%) had been camp residents for 2 years or less. Previous receipt of information on contraception was reported by 130 (83.9%) women, of whom 65 (50.0%) had received information during prenatal care. Fifty-four (34.8%) women knew at least two contraceptive methods. Overall, 47 (30.5%) of 154 women reported ever using contraception. Women who never used contraception cited lack of interest (66/107 [61.7%]) or knowledge (22/107 [20.6%]) and religious opposition (13/107 [12.1%]) as reasons. In the cohort overall, 33 (21.3%) women reported having had an induced abortion; 20 (60.6%) of these abortions were self-induced. CONCLUSION: Contraceptive knowledge among female camp residents was moderate, actual usage was low, and a considerable proportion reported a history of induced abortion. Efforts must be made to improve access to contraception to prevent unintended pregnancy, and to provide safe abortions and postabortion care.

Placental tumor necrosis factor-α protein expression during normal human gestation.

OBJECTIVE: Placental tumor necrosis factor-α (TNF-α) is a cell signaling protein. During pregnancy, TNF-α induces synthesis of matrix metalloproteinases (MMPs) which allows cytotrophoblasts to reach the spiral arteries deeper within the uterine decidua. TNF-α also augments apoptosis of vascular smooth muscle cells surrounding these arteries. In this study, chorionic villi TNF-α protein expression throughout normal human gestation were investigated. METHODS: Placental chorionic villi tissues obtained from elective surgical terminations of pregnancy and from uncomplicated term births were assayed using EIA kits (Cayman Chemicals, Ann Arbor, MI, Item # 589201). RESULTS: The median, 25th percentile and 75th percentile values in the first (N = 99), second (N = 58) and third trimester (N = 42) were: 36.46, 27.25, 45.90 pg/100 mg tissue; 55.43, 40.09, 110.88 pg/100 mg tissue; and 16.63, 9.32, 31.92 pg/100 mg tissue, respectively. CONCLUSIONS: Variations in placental TNF-α protein expression noted at different trimesters may suggest gestational age specific roles for the cytokine. The increase in TNF-α protein expression observed in the second trimester may be involved in upregulating synthesis of MMP and in augmenting apoptosis of vascular smooth muscle cells of the spiral arteries. A failure in this second trimester increase in TNF-α protein could contribute to gestational compromise.

Alternative Ultrasound Gel for a Sustainable Ultrasound Program: Application of Human Centered Design.

This paper describes design of a low cost, ultrasound gel from local products applying aspects of Human Centered Design methodology. A multidisciplinary team worked with clinicians who use ultrasound where commercial gel is cost prohibitive and scarce. The team followed the format outlined in the Ideo Took Kit. Research began by defining the challenge "how to create locally available alternative ultrasound gel for a low-resourced environment? The "End-Users," were identified as clinicians who use ultrasound in Democratic Republic of the Congo and Ethiopia. An expert group was identified and queried for possible alternatives to commercial gel. Responses included shampoo, oils, water and cornstarch. Cornstarch, while a reasonable solution, was either not available or too expensive. We then sought deeper knowledge of locally sources materials from local experts, market vendors, to develop a similar product. Suggested solutions gleaned from these interviews were collected and used to create ultrasound gel accounting for cost, image quality, manufacturing capability. Initial prototypes used cassava root flour from Great Lakes Region (DRC, Rwanda, Uganda, Tanzania) and West Africa, and bula from Ethiopia. Prototypes were tested in the field and resulting images evaluated by our user group. A final prototype was then selected. Cassava and bula at a 32 part water, 8 part flour and 4 part salt, heated, mixed then cooled was the product design of choice.

Fistula after attended delivery and the challenge of obstetric care capacity in the eastern Democratic Republic of Congo.

OBJECTIVE: To analyze the history of women with fistula in the eastern Democratic Republic of Congo (DRC) to understand the determinants of fistula development. METHODS: In a retrospective observational study, data were analyzed from a survey of all women who underwent surgical fistula repair at HEAL Africa Hospital, Goma, between April 1, 2009, and March 1, 2012. Characteristics and obstetric histories were obtained by self-report. RESULTS: The mean age of the 202 participants at treatment was 30.7 years (range 5-69). The mean duration of fistula was 45.6 months (range 0-600). In total, 171 (91.4%) fistulas were caused by obstructed labor, and 147 (86.5%) were vesicovaginal. Most women (129/175 [73.8%]) reported having received care during early labor under the supervision of a nurse or doctor in a healthcare facility. Among 176 women for whom delivery data were available, 102 (57.9%) delivered at a hospital, 42 (23.8%) at a health center, and 32 (18.2%) at home. Only 46 (26.3%) of 175 women were transferred to a higher level of care during labor. CONCLUSIONS: In the eastern DRC, efforts to enable transport to a healthcare facility and to encourage attended births must be accompanied by improvements in the capacity of existing facilities and in the training of staff to enable the timely diagnosis of labor abnormalities and appropriate intervention.