Medication abortion for adolescents in the United States: Strengthening the role of pediatric primary care providers.

BACKGROUND: Recent legal changes have led to mounting abortion restrictions in the United States (US), disproportionately impacting adolescents, who already face multifaceted barriers to abortion care. Informed by the framework of reproductive justice, adolescents who become pregnant deserve comprehensive, unbiased, and non-judgmental pregnancy options counseling, inclusive of all choices for pregnancy continuation and termination. Pediatric primary care providers are at the front lines of caring for adolescent patients' reproductive health needs and frequently diagnose pregnancy, provide pregnancy options counseling, and assist patients in accessing abortion care. They are uniquely poised to provide this care given their trusted, ongoing relationships with adolescent patients and their families, and their values of deep respect for adolescents' individuality and autonomy. METHODS: In this commentary, we aim to describe the medical and legal landscape of adolescent abortion access in the US and provide recommendations to support pediatric primary care providers' involvement in abortion care. We focus on medication abortion, as the provision of medication abortion has the potential to encompass a broad group of clinicians, including pediatric primary care providers. RESULTS: We discuss the importance of providing options counseling to adolescents within the reproductive justice framework, improving abortion education for pediatric providers, and expanding access to abortion care by supporting providers at an institutional level if they opt to provide medication abortions. CONCLUSION: In light of the current legal landscape, the role of pediatric primary care providers in ensuring adolescent access to abortion care is ever more critical. Although many pediatric and adolescent providers already provide this important care, we, a team of obstetricians/gynecologists and adolescent medicine physicians, echo prior calls for improved training and institutional support for pediatric providers to counsel about and provide abortion-related care. We hope that highlighting the role of pediatric providers in this sphere will help center the needs of adolescent patients and help them fulfill their family planning goals.

A Multidimensional and Longitudinal Exploratory Study of the Stability of Pregnancy Contexts in the United States.

Objective: Evaluate the longitudinal stability of six pregnancy contexts, including intention, in a diverse cohort of individuals experiencing delivery, abortion, or miscarriage. Methods: We enrolled individuals 16-44 years of age with pregnancies <24 weeks gestation in this longitudinal study between June 2014 and June 2015 in four US urban clinics. We assessed six pregnancy contexts (intention, wantedness, planning, timing, desirability, and happiness) at enrollment and 3-month follow-up. We constructed three-level categorical measures for each context defined as favorable, ambivalent, or unfavorable. We used Wilcoxon sign tests to evaluate changes in paired observations between pregnancy context measures over time and by pregnancy outcome. Results: Among 121 participants at median gestational age of 7 weeks and 3 days, we found intention, wantedness, planning, timing, and happiness remained unchanged from enrollment in early pregnancy to 3-month follow-up. Individuals demonstrated changes in desirability; pregnancy assessments shifted toward less desirable from enrollment to follow-up (p = 0.01) (i.e., desired to ambivalent, or ambivalent to undesired). Among participants choosing delivery (57%), assessments shifted toward more favorable planning (i.e., unplanned to ambivalent, or ambivalent to planned) (p < 0.01), and less favorable desirability (i.e., desired to ambivalent or ambivalent to undesired) (p < 0.01) at follow-up. Among participants choosing abortion (28%), assessments shifted toward more unfavorable planning (i.e., planned to ambivalent, or ambivalent to unplanned) at follow-up (p < 0.01). Conclusion: In multidimensional, longitudinal assessment, pregnant participants' perspectives on five of six pregnancy contexts remained unchanged between enrollment and 3-month follow-up; only desirability shifted. Pregnancy planning perspectives differed by pregnancy outcome.Human Research Subjects Protection Program: 1310012926.

Exploratory study of race- or ethnicity-based discrimination among patients receiving procedural abortion care.

OBJECTIVE: Explore relationships of race and ethnicity with experiences of race- or ethnicity-based discrimination during abortion care. STUDY DESIGN: English- or Spanish-speaking individuals aged 18 to 50 completed cross-sectional, self-administered online surveys within 30 days of procedural abortion at 5 Northeastern U.S. reproductive health clinics from June 2020 toFebruary 2021. We considered any affirmative response on the Discrimination in Medical Settings (DMS) scale evidence of race- or ethnicity-based discrimination. We performed bivariate analyses and logistic regression examining discrimination among Black non-Latinx, Latinx any race, Other race non-Latinx compared to White non-Latinx participants. We assessed associations between discrimination and healthcare quality and satisfaction. RESULTS: Participants (n = 163) averaged 27(±6) years and self-identified as Black non-Latinx (36.2%), White non-Latinx (28.8%), Latinx of any race (27.0%), and Other non-Latinx (8.0%). Most were publicly insured (52.8%) and <14 weeks gestation (90.8%).Overall, 15.3% reported race- or ethnicity-based discrimination during abortion care with Black non-Latinx more likely to report discrimination (23.7%; OR 7.00, 95% CI 1.50-32.59), while Latinx any race (15.9%, OR 4.26, 95% CI 0.83-21.74) and Other race non-Latinx participants (15.4%, OR 4.09, 95% CI 0.52-32.35) demonstrated statistically nonsignificant trend toward increased odds of discrimination compared to White non-Latinx (4.3%). Discrimination was associated with negative perceptions of: time with physician (p = 0.03), patient care involvement (p < 0.05), physician communication (p = 0.01), care quality (p = 0.02), and care satisfaction (p < 0.01). CONCLUSION: Racially minoritized participants were more likely to report race- or ethnicity-based discrimination during abortion care; Black non-Latinx reported highest odds of discrimination compared to White non-Latinx. Discrimination was associated with unfavorable healthcare quality measures. IMPLICATIONS: Race- or ethnicity-based discrimination during abortion care is disproportionately reported by racially minoritized populations, especially Black individuals, compared to White non-Latinx individuals. Discrimination is significantly associated with negative experiences of care. Future work should verify findings in different regions and larger studies, and design and test discrimination-reduction interventions.

What Is Long-Acting Reversible Contraception?

This JAMA Patient Page describes types of long-acting reversible contraception, how they are placed and removed, and their potential side effects.

The Impact of First-Person Abortion Stories on Community-Level Abortion Stigma: A Randomized Trial.

OBJECTIVE: We aimed to assess the impact of first-person abortion stories on community-level abortion stigma. METHODS: Between November 2018 and March 2019, we recruited participants and analyzed data from a nationally representative, probability-based online panel of U.S. adults, randomized to watch three first-person abortion video stories (intervention, n = 460) or three nature videos (control, n = 426). We measured community-level abortion stigma using the Community Abortion Attitudes Scale, Reproductive Experiences and Events Scale, and Community Level Abortion Stigma Scale at baseline, immediately after video exposure, and 3 months later. We dichotomized stigma change scores as decreased stigma compared with no change or increased stigma. Bivariate and logistic regression analysis accounted for complex survey methodology and sample weighting. RESULTS: Sample demographics reflected U.S. Census benchmarks (51% female, 68% White, 47% aged 18-44 years). Most participants (83.1%) completed the 3-month follow-up. Viewing the intervention videos was not associated with decreased stigma measured by Community Abortion Attitudes Scale or Community Level Abortion Stigma Scale immediately (odds ratio [OR], 0.80; 95% confidence interval [CI], 0.59-1.09; OR, 1.28; 95% CI, 0.93-1.75) or at the 3-month follow-up (OR, 0.86; 95% CI, 0.62-1.19; OR, 0.98; 95% CI, 0.70-1.37). Intervention exposure was associated with decreased stigma as measured by Reproductive Experiences and Events Scale immediately (OR, 1.74; 95% CI, 1.23-2.46); however, this association was not observed at the 3-month follow-up (OR, 0.98; 95% CI, 0.70-1.37). CONCLUSIONS: Exposure to first-person video stories may not decrease community-level abortion stigma among U.S. adults.

Comparative effectiveness of hysteroscopic and laparoscopic sterilization for women: a retrospective cohort study.

OBJECTIVE: To compare real-world effectiveness of hysteroscopic to laparoscopic sterilization. DESIGN: Retrospective cohort of Medicaid claims for hysteroscopic or laparoscopic sterilization procedures performed in California, 2008-2014. After excluding postpartum procedures, we applied log-linear (Poisson) event-history regression models for clustered person-period data, weighted for propensity to receive either sterilization procedures, and adjusted for sociodemographic and clinical variables to examine the poststerilization pregnancy rates. SETTING: Clinics, hospitals. PATIENT(S): Women aged 18-50 years with Medicaid claims between January 1, 2008, and August 31, 2014. INTERVENTION(S): Hysteroscopic or laparoscopic sterilization procedure. MAIN OUTCOME MEASURE(S): Poststerilization pregnancy measured by pregnancy-related claims. RESULT(S): Among women with hysteroscopic (n = 5,906) or laparoscopic (n = 23,965) sterilization, poststerilization pregnancy claims were identified for 4.74% of women after hysteroscopic sterilization and 5.57% after laparoscopic sterilization. The pregnancy rates decreased over time after either procedure. Twelve months after the procedure, the crude incidence of pregnancy claims was higher for hysteroscopic sterilization than for laparoscopic sterilization (3.26 vs. 2.61 per 100 woman-years), but the propensity-weighted adjusted incidence rate ratio was 1.06 (95% confidence interval [CI], 0.85-1.26). Between 13 and 24 months after the procedure, there were fewer pregnancies for women after hysteroscopic sterilizations than for those after laparoscopic sterilizations (adjusted incidence rate ratio, 0.63 [95% CI, 0.45-0.88]), with no statistically significant differences in later years. The cumulative pregnancy rates 5 years after sterilization were lower with hysteroscopic sterilization than with laparoscopic sterilization (6.26 vs. 7.22 per 100 woman-years; propensity-weighted, adjusted risk ratio, 0.76 [95% CI, 0.62-0.90]). The poststerilization pregnancy rates varied by age and race/ethnicity. CONCLUSION(S): The pregnancy rates after female sterilization are higher than expected, whether performed hysteroscopically or laparoscopically. These findings are reassuring that the effectiveness of hysteroscopic sterilization was not inferior to laparoscopic sterilization. CLINICAL TRIAL REGISTRATION NUMBER: NCT03438682.

Comparative Effectiveness and Safety of Intrauterine Contraception and Tubal Ligation.

BACKGROUND: Tubal ligation remains common in the USA, especially among low-income patients. OBJECTIVE: To compare the effectiveness and safety of intrauterine contraceptives (IUC) to laparoscopic tubal ligation for Medicaid clients. DESIGN: We partnered with patient and clinician stakeholders to conduct a retrospective cohort study using California Medicaid claims for patients who had an IUC placed or laparoscopic tubal ligation performed in 2008-2014, excluding procedures performed within 42 days of a birth. We applied log-linear (Poisson) event-history regression models for clustered person-period data to adjust for sociodemographic variables and pre-procedure health status when examining associations between these contraceptive procedures and claims related to contraceptive failure, complications, and pain in the first year post-procedure. KEY RESULTS: We identified 35,705 patients who had a levonorgestrel IUC placed, 23,628 patients who had a copper IUC placed, and 23,965 patients who underwent laparoscopic tubal ligation. In unadjusted analyses, rates of pregnancy within 1 year were similar following levonorgestrel IUC (2.40%) or copper IUC placement (2.99%) or tubal ligation (2.64%). In adjusted analyses, compared to tubal ligation, pregnancy was less common following placement of a levonorgestrel IUC (adj IRR 0.72, 95% CI 0.64-0.82) and similar with placement of a copper IUC (adj IRR 0.92, 95% CI 0.82-1.05). Procedural complications such as infection (0.35% vs. 2.91%) were significantly less common with IUC placement than tubal ligation. Claims for pelvic and abdominal pain decreased in frequency with time since all procedures; 6 to 12 months post-procedure, pelvic pain claims were less common after levonorgestrel IUC (adj IRR 0.69, 95% CI 0.65-0.73) or copper IUC placement (adj IRR 0.70, 95% CI 0.66-0.75) than tubal ligation. CONCLUSIONS: IUC appears at least as effective as laparoscopic tubal ligation at 1-year post-procedure with lower rates of infection and pelvic pain 6 to 12 months post-procedure. CLINICAL TRIAL REGISTRATION: NCT03438682.

Patient-Centered Safety Outcomes After Hysteroscopic Compared With Laparoscopic Sterilization.

OBJECTIVE: To evaluate the real-world safety of hysteroscopic compared with laparoscopic surgical sterilization. METHODS: We conducted a retrospective cohort study of Medicaid claims for hysteroscopic or laparoscopic sterilization procedures performed in California, 2008-2014, among women aged 18-50 years. After excluding postpartum procedures, we applied log-linear (Poisson) event-history regression models for clustered person-period data, weighted for propensity to receive either sterilization procedures, and adjusted for sociodemographic and clinical characteristics that may affect outcomes of interest to patients and physicians. We assessed the following outcomes: procedural complications, additional surgical procedures (eg, hysterectomy), repeat sterilization procedures, pelvic pain, pelvic inflammatory disease (PID), abdominal pain, nonabdominal pain, and abnormal uterine bleeding. RESULTS: We identified 5,906 women who had undergone hysteroscopic and 23,965 who had undergone laparoscopic sterilization. After adjusting for sociodemographic and health history, women who had hysteroscopic sterilization were less likely to have claims for procedural complications (eg, transfusion, P<.001) on the day of surgical sterilization and additional surgical procedures (eg, hysterectomy, P=.002 at day 2-3 months postprocedure) than laparoscopic sterilization. Claims for a repeat attempt at sterilization were more common after hysteroscopic sterilization within 1 year (adjusted incident rate ratio 3.48, 95% CI 2.69-4.27) and within 5 years (adjusted incident rate ratio 2.32, 95% CI 1.84-2.79) than laparoscopic sterilization. Claims for pelvic pain (adjusted incident rate ratio 0.77, 95% CI 0.65-0.92 at 2 years), abdominal pain (adjusted incident rate ratio 0.80, 95% CI 0.68-0.93 at 7-12 months), and PID (adjusted incident rate ratio 0.55, 95% CI 0.33-0.93 at 2 years) were less common after hysteroscopic than laparoscopic sterilization. Although abnormal uterine bleeding claims were more common after hysteroscopic than laparoscopic sterilization up to 12 months postprocedure (adjusted incident rate ratio 1.37, 95% CI 1.06-1.77 at 7-12 months), there were no significant differences between methods 1 year after the procedure. CONCLUSION: Compared with laparoscopic sterilization, hysteroscopic sterilization was followed by more claims for repeat sterilization procedures and abnormal uterine bleeding, but fewer procedural complications and fewer claims for pelvic or abdominal pain. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT03438682.

"Un abrazo a la distancia": An Exploration of Spanish-Speaking Women's Experiences with Pregnancy and Social Isolation in an Urban U.S. Setting.

Introduction: Research on Spanish-speaking Latina/Hispanic women's experiences during pregnancy is limited. Methods: We recruited women from urban, walk-in pregnancy testing clinics from June 2014 to June 2015. Women aged 16-44 years, at less than 24 weeks gestational age, who spoke either English or Spanish were eligible and completed an enrollment questionnaire and individual interview according to language preference. During qualitative interviews, we explored pregnancy intentions, initial reactions to a new pregnancy, and feelings about the impact of this pregnancy on relationships and daily life. Qualitative narrative content analysis was conducted using Atlas.ti software. Results: Among interviews with 31 Spanish-speaking Latina/Hispanic pregnant women, participants' average age was 28 years old with a mean gestational age of 7 weeks. We identified social isolation as the most common theme, characterized by four interwoven and overlapping subthemes: (1) sola-the experience of feeling alone; (2) familismo cercano-the importance of close relationships; (3) familismo lejano-overcoming long distance relationships; and (4) mi patria-preserving homeland cultural connectedness. Conclusions: Spanish-speaking Latina/Hispanic pregnant women described experiencing multiple aspects of social isolation. Language preference may suggest risk of social isolation, necessitating provider awareness and support initiatives to improve social support and lessen social isolation among newly pregnant, Spanish-speaking Latina women.

Characterizing community-level abortion stigma in the United States.

OBJECTIVE: Estimate community-level abortion stigma among U.S. adults and characterize factors associated with high stigma and less favorable opinions toward policies supportive of abortion care. STUDY DESIGN: We recruited respondents (U.S. adults, English-speaking) from a nationally representative, probability-based online panel in December 2018. We used multivariable logistic regression to identify factors associated with high abortion stigma using the Community Attitudes Abortion Scale (CAAS), a Reproductive Events and Experiences Scale (REES) subscale, and a Community Level Abortion Stigma Scale (CLASS) subscale. We measured favorability toward policies supportive of abortion care using widely used polling questions. RESULTS: Of 1800 eligible individuals contacted, 984 opened the invitation (54.6%) and 886 (90%) completed the survey. The majority demonstrated midrange stigma scores on all three scales. Increased likelihood of high stigma measured by CAAS was demonstrated among individuals reporting Catholic (OR 2.97, 95%CI 1.49-5.91) and Evangelical or Protestant religion (OR 4.78, 95%CI 2.53-9.00) compared to no religion, and Republican (OR 11.56, 95%CI 6.21-21.52) and Independent political affiliation (5.80, 95%CI, 3.17-10.60) compared to Democratic. Similar trends were seen with REES. Measured by CLASS, we found high stigma in Catholics compared to those with no religion (OR 1.91, 95%CI 1.09-3.32) and Blacks compared to Whites (OR 1.66, 95%CI 1.02-2.68). Identifying as Catholic, Evangelical or Protestant, and Republican were associated with holding less favorable opinions toward policies supportive of abortion care. Identifying as Catholic was the only characteristic associated with high stigma across all measures. CONCLUSIONS: Across multiple measurement tools, factors associated with high stigma and less favorable opinions toward policies supportive of abortion care include Catholic, Evangelical or Protestant religion and Republican political affiliation. IMPLICATIONS: Multiple measures are needed to fully understand the extent of and characteristics associated with community-level abortion stigma. Religion and political identity are frequently associated with high stigma. Understanding these relationships may aid in developing interventions to decrease stigma and in turn reduce barriers to abortion care.

Association of Pregnancy Contexts with Depression and Low Social Support in Early Pregnancy.

CONTEXT: Research into the relationship between pregnancy intention and perinatal depression or low social support is limited. Women's perspectives on pregnancy and their associations with perinatal depression could help in developing targeted efforts for screening and intervention. METHODS: In 2014-2015, 161 women seeking pregnancy testing or abortion care at clinics in New Haven, Connecticut, were surveyed. They were asked about pregnancy context (intentions, planning, wantedness, desirability, timing and happiness), and the Edinburgh Depression Screen (EDS) and the Modified Kendler Social Support Index (MKSSI) were used to identify possible antenatal depression and low social support, respectively. Multivariable logistic regression analysis was employed to examine associations between pregnancy context and these outcomes. RESULTS: On average, participants were 27 years old and at nine weeks' gestation. One-fifth reported a previous diagnosis of depression or anxiety, and 22% and 33% screened positive for depression (EDS scores of 13 or higher and 10 or higher, respectively); 52% received low social support (MKSSI score of 3.2 or less). Regression analysis found that pregnancies described as unintended, poorly timed or undesired were associated with depression at the higher cutoff (odds ratios, 3.2-4.5); all unfavorable pregnancy measures were associated with depression at the lower cutoff. Ambivalence regarding pregnancy timing, intention, wantedness and desirability was associated with increased odds of depression by either EDS score. Unplanned pregnancies and those about which the woman was ambivalent were associated with low social support. CONCLUSIONS: Findings support the need to screen women for depression early in pregnancy and to integrate assessments of pregnancy context into the evaluation of potential risk factors.

U.S. abortion care safety and quality: A summary of the national academies report for perinatologists.

Perinatologists provide or refer for abortion care when their patients need to end a risky or abnormal pregnancy. The National Academies of Science, Engineering, and Medicine (formally the Institute of Medicine) convened an expert committee to review and synthesize the robust literature on the safety and quality of abortion care for US women. This report is a seminal work in the sub-specialty of Complex Family Planning with important implications for Maternal-Fetal Medicine. The current article summarizes the findings of the National Academies' report for practicing perinatologists, putting its findings in the context of high-risk obstetrics. It considers the growing collaboration between the two sub-specialties.

SARS-CoV-2 infection of the placenta.

BACKGROUNDThe effects of the novel coronavirus disease 2019 (COVID-19) in pregnancy remain relatively unknown. We present a case of second trimester pregnancy with symptomatic COVID-19 complicated by severe preeclampsia and placental abruption.METHODSWe analyzed the placenta for the presence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) through molecular and immunohistochemical assays and by and electron microscopy and measured the maternal antibody response in the blood to this infection.RESULTSSARS-CoV-2 localized predominantly to syncytiotrophoblast cells at the materno-fetal interface of the placenta. Histological examination of the placenta revealed a dense macrophage infiltrate, but no evidence for the vasculopathy typically associated with preeclampsia.CONCLUSIONThis case demonstrates SARS-CoV-2 invasion of the placenta, highlighting the potential for severe morbidity among pregnant women with COVID-19.FUNDINGBeatrice Kleinberg Neuwirth Fund and Fast Grant Emergent Ventures funding from the Mercatus Center at George Mason University. The funding bodies did not have roles in the design of the study or data collection, analysis, and interpretation and played no role in writing the manuscript.

Development and Feasibility Testing of a Video Game to Reduce High-Risk Heterosexual Behavior in Spanish-Speaking Latinx Adolescents: Mixed Methods Study.

BACKGROUND: Similar to broader health disparities, Latinx adolescents have higher rates of high-risk sexual behavior resulting in pregnancy rates that are 2 times higher and sexually transmitted infection rates that are 5 to 8 times higher than non-Hispanic, white adolescents. Novel approaches are needed to reduce high-risk sexual behavior among Spanish-speaking Latinx adolescents who represent the fastest-growing group of US immigrants. OBJECTIVE: This study aimed to partner with Spanish-speaking Latinx adolescents in a participatory design process to develop and test a Spanish-language video game intervention to decrease high-risk heterosexual behavior. METHODS: This is an iterative, two-phase, mixed methods study. In phase 1, we conducted focus groups with Spanish-speaking Latinx adolescents to elicit feedback on the content and format of an existing English-language video game. Feedback was then incorporated into an expanded and culturally adapted Spanish-language video game. In phase 2, we pilot tested the feasibility, acceptability, and preliminary efficacy of the new Spanish-language video game intervention by measuring known antecedents to sexual behavior (intentions, self-efficacy, risk perception, and knowledge) assessed at enrollment and 12-week follow-up. We applied a thematic analysis to examine focus group feedback and a bivariate analysis to analyze pre- and postquantitative data. RESULTS: In phase 1, 15 Spanish-speaking Latinx adolescents provided feedback for further video game development. A Spanish-language video game was then produced and tested in phase 2. We recruited and enrolled 24 Spanish-speaking Latinx adolescents aged 15 to 17 years. Participants played the video game for an average of 4.2 hours during monitored sessions. Pilot testing demonstrated feasibility and acceptability; 65% (3/20) of participants stated that they would play it again, and 65% (3/20) said they would recommend it to friends. Condom-specific knowledge did significantly increase between baseline and follow-up (P=.007). Other variables of sexual behavior antecedents did not differ significantly between baseline and 12-week follow-up. CONCLUSIONS: An iterative participatory design process in partnership with Spanish-speaking adolescents produced an innovative and acceptable Spanish-language video game intervention aimed at decreasing high-risk sexual behavior in adolescents. Pilot testing demonstrated preliminary feasibility and yielded essential information for further video game development.

Is Periconceptional Substance Use Associated with Unintended Pregnancy?

Background: To evaluate the relationship between periconceptional (period before and/or after conception) substance use and unfavorable pregnancy contexts, including unintended pregnancy. Materials and Methods: This is a cross-sectional analysis of English- or Spanish-speaking women aged 16-44 years with pregnancies <24 weeks' gestation presenting to pregnancy testing clinics and enrolled between June 2014 and June 2015. Participants self-reported periconceptional substance use (tobacco, alcohol, marijuana, and other illicit substances during the 3 months before enrollment), and pregnancy "contexts," including pregnancy intention, wantedness, planning, timing, desirability, and happiness. Multivariable logistic regression was performed adjusting for potential confounding variables. Results: We enrolled 123 women, averaging 27 ± 6 years, and mean gestational age 7.5 ± 3.0 weeks. Most participants were black, non-Hispanic (37%), or Hispanic (46%), and chose to complete the study in English (69%). Sixty-five percent participants reported use of one or more substances during prior 3 months: alcohol (54%), tobacco (31%), and marijuana (21%). In multivariate analysis, periconceptional alcohol use was associated with increased odds of unintended or ambivalent pregnancy and unwanted or mixed feelings regarding pregnancy (odds ratios [OR] = 3.29, 95% confidence interval [CI] 1.08-10.08 and OR = 2.81, 95% CI 1.07-7.36, respectively). Weekly or daily tobacco use was associated with unhappiness about pregnancy (OR = 7.56, 95% CI 1.65-34.51) and undesired or unsure pregnancy (OR = 4.00, 95% CI 1.14-14.06). Conclusions: Periconceptional alcohol or tobacco use demonstrates increased odds of specific unfavorable pregnancy contexts, including pregnancy described as undesired, unintended, unwanted, and unhappiness with pregnancy. Primary prevention of periconceptional substance use and the negative effects of alcohol and tobacco may be improved by increasing contraception access for women at risk for unfavorable pregnancy contexts.

"I'm used to doing it by myself": exploring self-reliance in pregnancy.

BACKGROUND: Self-reliance (the need to rely on one's own efforts and abilities) is cited as a potential coping strategy for decreased or absent social support during pregnancy. Little data exists on how women view self-reliance in pregnancy. METHODS: We recruited women from urban, walk-in pregnancy testing clinics from June 2014-June 2015. Women aged 16 to 44 and at less than 24 weeks gestational age were eligible. Participants completed an enrollment survey and in-person, semi-structured interviews. We used framework analysis to identify key concepts and assess thematic relationships. RESULTS: Eighty-four English-speaking women completed qualitative interviews. Participants averaged 26 years of age and 7 weeks estimated gestational age. Most identified as Black (54%) or Hispanic (20%), were unemployed or homemakers (52%), unmarried (92%), and had at least one child (67%). Most did not intend to get pregnant (61%) and planned to continue their pregnancy and parent (65%). We identified self-reliance as a prevalent concept that almost half (48%) of participants discussed in relationship to their pregnancy. Self-reliance in pregnancy consisted of several subthemes: 1) past experiences, 2) expectations of motherhood, 3) financial independence, 4) decision making, and 5) parenting. CONCLUSIONS: Self-reliance is an important aspect of women's reproductive lives and is threaded through women's past and current thoughts, feelings, experiences and decisions about pregnancy. Women's belief in their own self-reliance as well as a recognition of the limits of self-reliance merits further research, especially as a potential strategy to cope with decreased or absent social support during pregnancy.

Development and Feasibility Testing of a Videogame Intervention to Reduce High-Risk Sexual Behavior in Black and Hispanic Adolescents.

Objective: Develop and test feasibility of a mobile videogame intervention to decrease high-risk sexual behavior in black and Hispanic adolescents. Materials and Methods: Iterative design to develop intervention in partnership with target audience. Feasibility and preliminary impact data collected at baseline, following 2-3 hours of gameplay and at 8-week follow-up. Results: Twenty-six 15-17-year-olds completed pilot testing: 16 (62%) were male, 20 (77%) black or Hispanic. Pilot testing demonstrated feasibility, including producing a usable videogame prototype, incorporating videogame testing within a high school, and participants' acceptability of the videogame. Participants' gameplay experience reflected that most would play the videogame again (77%), stated that they felt responsible for the choices they made in the videogame (73%), and would tell their friends to play the videogame (58%). Most suggested adding more videogame content to further engage participants. From baseline to follow-up, participants demonstrated improvements in condom and contraception self-efficacy (P = 0.003), risk perceptions (P = 0.009), and high-risk sexual behavior knowledge (P < 0.0001). Among black or Hispanic adolescents, we found improvements in summary measures of intentions (P = 0.04), self-efficacy (P = 0.003), risk perceptions (P = 0.002), and sexual knowledge (P = 0.0002). Adolescents with previous sexual experience showed similar improvements. Conclusion: Pilot testing of an innovative videogame, developed in partnership with the target audience, demonstrated feasibility and preliminary impact with this cohort of black or Hispanic adolescents. We developed a usable videogame prototype and gained important data about how to enhance the next videogame iteration. Future plans include targeting an older age group to maximize our ability to measure potential impact among sexually experienced adolescents.