Equity and Justice in Family Medicine Clinical Care and Teaching Must Incorporate a Reproductive Justice Framework.

Since European settlement, the United States has controlled the reproduction of communities of color through tactics ranging from forced pregnancies, sterilizations, and abortions to immigration policies and policies that separate children from their families. Lesbian, gay, bisexual, transgender, queer (or questioning), asexual, intersex, and gender diverse people (LGBTQIA+) have been persecuted for sexual behavior and gender expression, and also restricted from having children. In response, women of color and LGBTQIA+ communities have organized for Reproductive Justice (RJ) and liberation. The Reproductive Justice framework, conceived in 1994 by the Women of African Descent for Reproductive Justice, addresses the reproductive health needs of Black women and communities from a broad human rights perspective. Since then, the framework has expanded with an intersectional approach to include all communities of color and LGBTQIA+ communities. Notwithstanding, reproductive injustice negatively impacts the health of already marginalized and oppressed communities, which is reflected in higher rates of maternal mortality, infant mortality, infertility, preterm births, and poorer health outcomes associated with race-based stress. While the impact of racial injustice on disparate health outcomes is increasingly addressed in family medicine, Reproductive Justice has not been universally incorporated into care provision or education. Including the RJ framework in family medicine education is critical to understanding how structural, economic, and political factors influence health outcomes to improve health care delivery from a justice and human rights perspective. This commentary describes how an RJ framework can enhance medical education and care provision, and subsequently identifies strategies for incorporating Reproductive Justice teaching into family medicine education.

Standardizing abortion research outcomes (STAR): Results from an international consensus development study.

OBJECTIVE: To develop a minimum data set, known as a core outcome set, for future abortion randomized controlled trials. STUDY DESIGN: We extracted outcomes from quantitative and qualitative systematic reviews of abortion studies to assess using a modified Delphi method. Via email, we invited researchers, clinicians, patients, and healthcare organization representatives with expertise in abortion to rate the importance of the outcomes on a 9-point Likert scale. After 2 rounds, we used descriptive analyses to determine which outcomes met the predefined consensus criteria. We finalized the core outcome set during a series of consensus development meetings. RESULTS: We entered 42 outcomes, organized in 15 domains, into the Delphi survey. Two-hundred eighteen of 251 invitees (87%) provided responses (203 complete responses) for round 1 and 118 of 218 (42%) completed round2. Sixteen experts participated in the development meetings. The final outcome set includes 15 outcomes: 10 outcomes apply to all abortion trials (successful abortion, ongoing pregnancy, death, hemorrhage, uterine infection, hospitalization, surgical intervention, pain, gastrointestinal symptoms, and patients' experience of abortion); 2 outcomes apply to only surgical abortion trials (uterine perforation and cervical injury), one applies only to medical abortion trials (uterine rupture); and 2 apply to trials evaluating abortions with anesthesia (over-sedation/respiratory depression and local anesthetic systemic toxicity). CONCLUSION: Using robust consensus science methods we have developed a core outcome set for future abortion research. IMPLICATIONS: Standardized outcomes in abortion research could decrease heterogeneity among trials and improve the quality of systematic reviews and clinical guidelines. Researchers should select, collect, and report these core outcomes in future abortion trials. Journal editors should advocate for core outcome set reporting.

What contraception do women use after abortion? An analysis of 319,385 cases from eight countries.

Contraception is an essential element of high-quality abortion care. However, women seeking abortion often leave health facilities without receiving contraceptive counselling or methods, increasing their risk of unintended pregnancy. This paper describes contraceptive uptake in 319,385 women seeking abortion in 2326 public-sector health facilities in eight African and Asian countries from 2011 to 2013. Ministries of Health integrated contraceptive and abortion services, with technical assistance from Ipas, an international non-governmental organisation. Interventions included updating national guidelines, upgrading facilities, supplying contraceptive methods, and training providers. We conducted unadjusted and adjusted associations between facility level, client age, and gestational age and receipt of contraception at the time of abortion. Overall, postabortion contraceptive uptake was 73%. Factors contributing to uptake included care at a primary-level facility, having an induced abortion, first-trimester gestation, age ≥25, and use of vacuum aspiration for uterine evacuation. Uptake of long-acting, reversible contraception was low in most countries. These findings demonstrate high contraceptive uptake when it is delivered at the time of the abortion, a wide range of contraceptive commodities is available, and ongoing monitoring of services occurs. Improving availability of long-acting contraception, strengthening services in hospitals, and increasing access for young women are areas for improvement.

What Factors Contribute to Postabortion Contraceptive Uptake By Young Women? A Program Evaluation in 10 Countries in Asia and sub-Saharan Africa.

BACKGROUND: Unintended pregnancy disproportionately affects young women and adolescents in developing countries. The abortion care setting offers a unique opportunity for adolescents and young women to access a full range of contraceptive services. This evaluation assesses the factors that influence contraceptive uptake among adolescents and young women seeking abortion care in health facilities. METHODS: Following provider training, we analyzed client log book data from 921,918 abortion care cases in 4,881 health facilities in 10 countries from July 2011 through June 2015. Log book data included client characteristics such as age, pregnancy gestation, type of service provided, and contraceptive method provision. Health facility characteristics were obtained through administration of a site baseline form prior to initiation of programmatic support by Ipas, an international NGO. Programmatic support included integration of postabortion contraceptive services with abortion care, improvements in commodities logistics, health worker training, upgraded recordkeeping, and post-training follow-up with providers and sites to solve problems and improve performance. We analyzed abortion cases by 3 age categories, ≤19 years, 20-24 years, and ≥25 years, and conducted unadjusted and adjusted analyses for the primary outcomes of interest: receipt of a contraceptive method at the time of care; type of contraceptive method selected; and the client, clinical care, and facility characteristics associated with contraceptive uptake. RESULTS: Overall, 77% of women left the facility with a contraceptive method. The majority (84%) of contraceptive acceptors selected a short-acting method, especially oral contraceptives. In the adjusted model, women ≤19 were less likely to choose a method than women 25 years or older (odds ratio [OR], 0.87; 95% confidence interval [CI], 0.79 to 0.96). Adolescents and young women were also significantly less likely to choose a long-acting, reversible contraceptive than those ages 25 or older (≤19 years: OR, 0.59; 95% CI, 0.52 to 0.67; 20-24 years: OR, 0.68; 95% CI, 0.63 to 0.73). Women treated by an Ipas-trained provider were significantly more likely to select postabortion contraception than women treated by non-Ipas-trained providers (OR, 1.37; 95% CI, 1.20 to 1.57). CONCLUSIONS: Programmatic support to health systems, including provider training in contraceptive counseling and provision, was associated with women's higher acceptance of postabortion contraception. However, gaps remained for young women, especially adolescents, who were significantly less likely than older women to accept postabortion contraception. Health systems and facilities should pay increased attention to meeting the contraceptive needs of young women and adolescents.

Abortion care for adolescent and young women.

BACKGROUND: Unintended pregnancy among adolescents (10-19years) and young women (20-24years) is a global public health problem. Adolescents face challenges in accessing safe abortion care. OBJECTIVE: To determine, via a systematic data review, whether abortion care for adolescent and young women differs clinically from that for older women. METHODS: In a comprehensive data review, the Cochrane Central Register of Controlled Trials, MEDLINE, and POPLINE databases were searched from the earliest data entered until November 2012. Randomized controlled trials and observational studies comparing effectiveness, safety, acceptability, and long-term sequelae of abortion care between adolescent/young women and older women were identified. Two reviewers independently extracted data, and the Cochrane guidelines and Newcastle-Ottawa Scale were used for quality assessment. RESULTS: In total, there were 25 studies including 346 000 women undergoing first- and second-trimester medical abortion, vacuum aspiration, or dilation and evacuation. Effectiveness and overall complications were similar among age groups. However, younger women had an increased risk for cervical laceration and a decreased risk of uterine perforation and mortality. Satisfaction and long-term depression were similar between age groups. Except for less uptake of intrauterine devices among adolescents, age did not affect post-abortion contraception. CONCLUSIONS: Evidence from various healthcare systems indicates that abortion is safe and efficacious among adolescent and young women. Clinical services should promote access to safe abortion for adolescents.

A review of evidence for safe abortion care.

BACKGROUND: The provision of safe abortion services to women who need them has the potential to drastically reduce or eliminate maternal deaths due to unsafe abortion. The World Health Organization recently updated its evidence-based guidance for safe and effective clinical practices using data from systematic reviews of the literature. MATERIALS AND METHODS: Systematic reviews pertaining to the evidence for safe abortion services, from pre-abortion care, medical and surgical methods of abortion and post-abortion care were evaluated for relevant outcomes, primarily those relating to safety, effectiveness and women's preference. RESULTS: Sixteen systematic reviews were identified and evaluated. The available evidence does not support the use of pre-abortion ultrasound to increase safety. Routine use of cervical preparation with osmotic dilators, mifepristone or misoprostol after 14 weeks gestation reduces complications; at early gestational ages, surgical abortions have very few complications. Prophylactic antibiotics result in lower rates of post-surgical abortion infection. Pain medication such as non-steroidal anti-inflammatories should be offered to women undergoing abortion procedures; acetaminophen, however, is not effective in reducing pain. Women who are eligible should be offered a choice between surgical (vacuum aspiration or dilation and evacuation) and medical methods (mifepristone and misoprostol) of abortion when possible. Modern methods of contraception can be safely initiated immediately following abortion procedures. CONCLUSIONS: Evidence-based guidelines assist health care providers and policymakers to utilize the best data available to provide safe abortion care and prevent the millions of deaths and disabilities that result from unsafe abortion.

Patient understanding of oral contraceptive pill instructions related to missed pills: a systematic review.

BACKGROUND: Instructions on what to do after pills are missed are critical to reducing unintended pregnancies resulting from patient non-adherence to oral contraceptive (OC) regimens. Missed pill instructions have previously been criticized for being too complex, lacking a definition of what is meant by "missed pills," and for being confusing to women who may not know the estrogen content of their formulation. To help inform the development of missed pill guidance to be included in the forthcoming US Selected Practice Recommendations, the objective of this systematic review was to evaluate the evidence on patient understanding of missed pill instructions. STUDY DESIGN: We searched the PubMed database for peer-reviewed articles that examined patient understanding of OC pill instructions that were published in any language from inception of the database through March 2012. We included studies that examined women's knowledge and understanding of missed pill instructions after exposure to some written material (e.g., patient package insert, brochure), as well as studies that compared different types of missed pill instructions on women's comprehension. We used standard abstract forms and grading systems to summarize and assess the quality of the evidence. RESULTS: From 1620 articles, nine studies met our inclusion criteria. Evidence from one randomized controlled trial (RCT) and two descriptive studies found that more women knew what to do after missing 1 pill than after missing 2 or 3 pills (Level I, good, to Level II-3, poor), and two descriptive studies found that more women knew what to do after missing 2 pills than after missing 3 pills (Level II-3, fair). Data from two descriptive studies documented the difficulty women have understanding missed pill instructions contained in patient package inserts (Level II-3, poor), and evidence from two RCTs found that providing written brochures with information on missed pill instructions in addition to contraceptive counseling significantly improved knowledge of how to manage missed pills for up to three months compared to contraceptive counseling alone (Level I, fair). Evidence from one RCT found that graphic-based missed pill instructions were better than text-only instructions (Level I, good), and data from two RCTs found that less information resulted in improved comprehension (Level I, good to fair). Evidence from one descriptive study found that many women missing pills did not intend to follow recommended actions per missed pill instructions despite understanding the guidance (Level II-3, poor). CONCLUSIONS: There is wide variability in the percent of women having correct knowledge on what to do when pills are missed after exposure to written missed pills instructions, with more women knowing what to do after missing 1 pill than after missing 2 or 3 pills. Women have difficulty understanding missed pill instructions contained in patient package inserts. Providing written brochures with information on missed pill instructions in addition to contraceptive counseling may improve knowledge of how to manage missed pills. Graphic-based missed pill instructions and those containing less information may result in improved comprehension. Even with clear instructions, many women missing pills may choose not to follow the recommended actions.

The effect of follow-up visits or contacts after contraceptive initiation on method continuation and correct use.

BACKGROUND: We conducted a systematic review to assess whether follow-up visits or contacts after a woman begins using contraception improve method continuation and correct use. STUDY DESIGN: We searched the PubMed database for all peer-reviewed articles in any language published from database inception through May 2012 that examined the effect of a structured follow-up schedule of visits or contacts on contraceptive use. We included studies that compared women who initiated a method of contraception with a certain follow-up schedule compared to women with a different follow-up schedule or no follow-up at all. To be included, studies must have compared groups on a measure of contraceptive use (e.g., pregnancy, correct use, consistent use, method discontinuation including expulsion). Though not ideally suited to answer our review question, studies in which women used a variety of contraceptive methods but results were not stratified by method type were included. RESULTS: Four studies met our inclusion criteria (Level I, poor to II-2, poor). Two studies examined the effect of a specific follow-up visit schedule on intrauterine device (IUD) continuation: one examining frequency of visits and one examining the timing of the first follow-up visit. Women with more frequent follow-up visits did not have a statistically significant difference in proportion of removals for medical reasons compared with women who had fewer follow-up visits; among women who had their IUDs removed for medical reasons, those who had more frequent follow-up visits had a longer mean time of use prior to removal. The other study found more removals and shorter continuation among women with a follow-up visit at 1 week compared to women with a follow-up visit at 1 month after IUD insertion (no statistical tests reported). Two studies examined the effect of follow-up phone calls compared to no follow-up phone calls after an initial family planning visit among adolescents initiating a variety of contraceptive methods. Neither of the two studies found any differences in method continuation or correct use between study groups. CONCLUSIONS: It is difficult to determine what effect, if any, follow-up visits or contacts have on contraceptive method continuation or correct use. Few studies were identified, and those that were identified were mostly of poor quality, were not method specific and had either poor patient compliance with follow-up visits or poor phone contact completion rates.

Effect of missed combined hormonal contraceptives on contraceptive effectiveness: a systematic review.

BACKGROUND: Combined hormonal contraceptives (CHCs) are popular methods of reversible contraception in the United States, but adherence remains an issue as reflected in their lower rates of typical use effectiveness. The objective of this systematic review was to evaluate evidence on the effect of missed CHCs on pregnancy rates as well as surrogate measures of contraceptive effectiveness (e.g., ovulation, follicular development, changes in hormone levels, cervical mucus quality). STUDY DESIGN: We searched the PubMed database for peer-reviewed articles published in any language from database inception through April 2012. We included studies that examined measures of contraceptive effectiveness during cycles with extended hormone-free intervals or nonadherence (e.g., omission of pills, delayed patch replacement) on days not adjacent to the hormone-free interval. We used standard abstract forms and grading systems to summarize and assess the quality of the evidence. RESULTS: The search strategy identified 1387 articles, of which 26 met our study selection criteria. There is wide variability in the amount of follicular development and risk of ovulation among women who extended the pill-free interval to 8-14 days; in general, the risk of ovulation was low, and among women who did ovulate, cycles were usually abnormal (i.e., low progesterone levels, small follicles and/or poor cervical mucus) (Level I, good, indirect to Level II-3, fair, indirect). Studies of women who missed one to four consecutive pills or 1-3 consecutive days of delay before patch replacement at times other than adjacent to the hormone-free interval reported little follicular activity and low risk of ovulation (Level I, fair, indirect to Level II-3, poor, indirect). Studies comparing 30 mcg versus 20 mcg mc ethinyl estradiol pills showed more follicular activity when 20 mcg ethinyl estradiol pills were missed (Level I, good, indirect). CONCLUSION: Most of the studies in this evidence base relied on surrogate measures of pregnancy risk and ranged in quality. For studies providing indirect evidence on the effects of missed CHCs, it is unclear how differences in surrogate measures correspond to pregnancy risk. Fewer studies examined the transdermal patch and vaginal ring than combined oral contraceptives.

When can a woman start combined hormonal contraceptives (CHCs)? A systematic review.

BACKGROUND: Conventional methods of initiating combined hormonal contraceptives (CHCs), specifically combined oral contraceptives (COCs), the contraceptive patch and the contraceptive ring, require that women delay starting CHCs until menses begin, during which time a woman may be at risk of unintended pregnancy. The objective of this systematic review is to examine the evidence on the risk of becoming pregnant after starting the method (contraceptive effectiveness including surrogate measures such as ovarian follicular development and hormone levels), risk of already being pregnant, side effects and continuation when starting CHCs on different days of the menstrual cycle. STUDY DESIGN: We searched the MEDLINE database for all articles (in all languages) published in peer-reviewed journals from inception through March 2012 for evidence relevant to starting CHCs on different days of the menstrual cycle and the outcomes of contraceptive effectiveness (including ovarian follicular development and hormonal levels), side effects and continuation rates. RESULTS: From 1635 reviewed articles, 18 studies met our inclusion criteria. Evidence from four studies suggests that neither the risk of inadvertently starting COCs in a woman who is pregnant nor the risk of pregnancy after COC initiation are affected by the cycle day on which COCs are started. While follicular activity increased as the cycle day on which COCs were initiated increased, no women ovulated when starting on Day 5. When starting on Day 7, there was no increase in ovulation for a 30-mcg pill but a significant increase in ovulation with a 20-mcg pill compared with starting on Day 1. Evidence from two small studies suggests that 7 days of pills leads to inhibition of ovulation. One small study suggests that only 3 days of ring use is needed to inhibit ovulation, but this was following one complete treatment cycle of ring use. Evidence also suggests that starting CHCs on any day of the cycle does not affect bleeding problems or other side effects for both COCs and the patch. While starting CHCs via Quick Start (starting on the day of the health care visit) may initially increase continuation compared with more conventional starting strategies, evidence suggests that this difference disappears over time. CONCLUSION: The body of evidence suggested that (a) pregnancy rates did not differ by the timing of CHC initiation; (b) the more follicular activity that occurred prior to starting COCs, the more likely ovulation was to occur; however, no ovulations were seen when COCs were started at a follicle diameter of 10 mm (mean cycle day=7.6) or when the ring was started at follicle diameter of 13 mm (median cycle day=11); (c) bleeding patterns and other side effects did not vary with the timing of CHC initiation and (d) continuation rates of CHCs were initially improved by Quick Start, but differences between groups disappeared over time.

Appropriate follow up to detect potential adverse events after initiation of select contraceptive methods: a systematic review.

BACKGROUND: After a woman initiates certain methods of contraception [e.g., hormonal methods, intrauterine devices (IUDs)], she is generally asked to return at some interval for a follow-up visit; however, is it unclear whether follow up is needed, what an appropriate follow-up schedule is and what should be done at follow-up visits. METHODS: We conducted four separate searches in the PubMed database for all peer-reviewed articles in any language published from database inception through April 2012 that examined the following health outcomes for combined hormonal contraceptives (CHCs), IUDs or medroxyprogesterone acetate (DMPA): (a) incidence of hypertension among women who began using a CHC compared to women not using a CHC; (b) incidence of migraine among women who began using a CHC compared to women not using a CHC; (c) incidence of pelvic inflammatory disease (PID) among women who began using an IUD compared to women who started another form or used no method of contraception or examined incidence of PID at two or more time periods after IUD insertion and (d) whether initial weight gain predicts future weight gain among women who began using DMPA. The quality of each study was assessed using the United States Preventive Services Task Force grading system. RESULTS: A total of 15 studies met our inclusion criteria: 5 examined hypertension and combined oral contraceptive (COC) use, 7 examined PID and IUD use and 3 examined weight gain after DMPA initiation. No studies that examined migraine after CHC initiation met our inclusion criteria. Few women developed hypertension after initiating COCs, and studies examining increases in blood pressure after COC initiation found mixed results (Level I, fair to II-2, fair). Among women who had a copper IUD inserted, there was little difference in incidence of PID, or IUD removal for PID, compared with women who initiated DMPA, a hormone-releasing IUD, or COCs (Level I, good to Level II-2, fair). Studies that examined when women were diagnosed with PID after IUD insertion found mixed results. The study with the largest sample size found a much greater incidence of PID in the first 20 days after insertion, with very low rates of PID up to 8 years postinsertion (Level I, good to Level II-3, poor). Studies that examined weight gain after DMPA initiation found that weight gain >5% of baseline weight at 6 months was associated with greater mean change in weight and greater mean change in body mass index at follow-up times ranging from 12 to 36 months (Level II-2, fair to Level II-3, fair). CONCLUSIONS: Evidence on select adverse events associated with initiation of contraceptive use is limited but does not suggest increased risk of hypertension among COC users or increased risk of PID among IUD users. DMPA users who gain >5% of baseline body weight may be at increased risk of future weight gain.

Pregnancy outcomes with an IUD in situ: a systematic review.

BACKGROUND: While intrauterine devices (IUDs) provide highly effective contraception, pregnancies among IUD users do rarely occur. The objective of this systematic review is to assess the evidence about risks for adverse pregnancy outcomes among women who conceive with an IUD in situ. METHODS: We searched MEDLINE, POPLINE, EMBASE and LILACS databases from inception through April 2011 for peer-reviewed articles containing evidence related to pregnancy outcomes among women who conceived while using copper (Cu) and levonorgestrel-releasing (LNG) IUDs. RESULTS: Nine articles met our inclusion criteria. Women with retained IUDs were at the greatest risk of adverse pregnancy outcomes, including spontaneous abortion, preterm delivery, septic abortion and chorioamnionitis. Cu-IUD removal decreased risks but not to the baseline risk of pregnancies without an IUD. One case series examined the LNG-IUD; when left in situ, 8 in 10 ended in spontaneous abortions. CONCLUSION: Pregnancies complicated by a remaining IUD in situ were at greater risk of adverse pregnancy outcomes. Early IUD removal appeared to improve outcomes but did not entirely eliminate risks.

A descriptive analysis of abortion training in family medicine residency programs.

BACKGROUND AND OBJECTIVES: Access to abortion services in the United States is declining. While family physicians are well suited to provide this care, limited training in abortion occurs in family medicine residency programs. This study was designed to describe the structure of currently available training and the experience of residents participating in these programs. METHODS: E-mail questionnaires were sent to key faculty members and third-year residents in nine programs that have required abortion training. These faculty members and a sample of residents also completed semi-structured interviews. RESULTS: Residency programs varied in the amount of time dedicated to the procedural aspects of abortion training, ranging from 2 to 8 days, and also in non-procedural aspects of training such as values clarification and didactics. Themes that emerged from interviews with residents included the benefit of training with respect to technical skills and continuity of care. In addition, residents valued discussion of the emotional aspects of abortion care and issues relating to performing abortions after graduation from residency. CONCLUSIONS: While the details of the curricula vary, residents in programs with required abortion training generally felt positively about their experiences and felt that abortion was an appropriate procedure for family physicians to provide. Residents emphasized the importance of both non-procedural and technical aspects of training.

Integrating abortion training into family medicine residency programs.

BACKGROUND AND OBJECTIVES: Family physicians provide many office-based procedures in primary care settings. While first-trimester abortion is a procedure appropriate for and performed by family physicians, few residency programs offer routine training in this skill. This study explored the experience of residency programs that have initiated or are in the process of initiating required abortion training. METHODS: Faculty members responsible for abortion training curricula in identified programs completed questionnaires and semi-structured interviews. RESULTS: Faculty members from nine programs with required training and seven programs interested in initiating this training were included in the study. Factors that assisted in curriculum development included the support of family medicine and obstetrician-gynecologist faculty. Commonly encountered challenges included the need for dedicated resources, inter-specialty conflict, and limited access to training sites. CONCLUSIONS: Family medicine programs can be successful at developing required abortion training. Collaboration with colleagues inside and outside the family medicine department and with receptive training sites will benefit programs interested in such.