Traveling for rights: Abortion trends in New Mexico after passage of restrictive Texas legislation.

OBJECTIVES: To determine the proportion of abortions provided to patients from Texas in New Mexico before and after the 2013 enactment of Texas House Bill 2 (HB2), an omnibus bill of abortion restrictions, and to compare the gestational ages at which Texans presented for abortion in New Mexico before and after HB2. STUDY DESIGN: We conducted a chart review of Texas and New Mexico patients obtaining an abortion in New Mexico abortion clinics before HB 2 was signed and implemented (time period 1: January 1, 2012 to December 31, 2012) and after HB 2 went into effect (time period 2: May 1, 2014 to April 30, 2015). We used random sampling of corresponding 7-day periods (by week number during the one-year sample) to obtain data until we reached the desired sample of at least 300 patients. We compared proportions of individuals from Texas obtaining abortions and the gestational age at which they presented in the two time periods. RESULTS: We abstracted data from 350 and 300 Texas and New Mexico patients, respectively. The proportion of procedures provided to women from Texas increased from 10 (3%) pre-HB2 to 43 (14%) post-HB2 (p < 0.0001). The proportion of procedures in Texas patients at 13 to ≤24 weeks increased from 1 of 29 (3%) pre-HB2 to 10 of 38 (26%) post-HB2 (p = 0.012). CONCLUSION: The proportion of Texans scheduling abortions in New Mexico within the first 24 weeks of gestation increased after passage of HB2. Restrictive legislation may force more people to travel across state lines to obtain abortion care. IMPLICATIONS: Patients residing in Texas and seeking abortion care in Texas experienced barriers to abortion care, likely related to restrictions imposed by HB2.

Nitrous Oxide Compared With Intravenous Sedation for Second-Trimester Abortion: A Randomized Controlled Trial.

OBJECTIVE: To assess whether inhaled nitrous oxide is noninferior to intravenous (IV) sedation for pain control during outpatient surgical abortion between 12 and 16 weeks of gestation. METHODS: We enrolled women undergoing surgical abortion at 12-16 weeks of gestation into a multisite, double-blind clinical trial. Participants were randomized to sedation with nitrous oxide (70% nitrous/30% oxygen) or IV fentanyl (100 micrograms) and midazolam (2 mg). Paracervical block was administered to both groups. The primary outcome measure was immediate postabortion recall of maximum pain on a 100-mm visual analog scale. RESULTS: Between August 2016 and March 2017, we assessed 170 women for eligibility and enrolled 39, 19 in the nitrous group and 20 in the IV sedation group. Seven participants in the nitrous group (36.8%) required conversion to IV sedation for inadequate pain control. No participants in the IV sedation group required additional medication. The proportion of women requiring additional pain control in the nitrous group exceeded our predefined stopping rule. Intention-to-treat analysis demonstrated that immediate postabortion visual analog scale pain scores were lower by 20.1 mm (95% CI 1.6-38.6) in women randomized to IV sedation than in women randomized to nitrous. CONCLUSION: Intravenous sedation is a better choice than inhaled nitrous oxide for pain control in second-trimester abortion. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT02755090.

Women's experiences with immediate postpartum intrauterine device insertion: a mixed-methods study.

OBJECTIVE: To describe women's pain and experiences with immediate postpartum intrauterine device (IUD) insertion (IPPI) following vaginal delivery using a ring forceps insertion technique. STUDY DESIGN: This observational mixed-methods study included women who underwent successful IPPI using ring forceps, with and without epidural analgesia. To describe women's pain during the procedure, we recruited women during antenatal care and at the time of admission for delivery until we collected at least 30 sets of pain scores at two time points (preprocedure and immediately postprocedure) in both groups using two instruments: 100-mm visual analogue scale (VAS) and a 4-point Likert verbal rating scale (VRS) (0=none, 1=mild, 2=moderate, 3=severe). After placing the IUD, physicians rated ease of IUD insertion. A subset of participants in both groups underwent semistructured interviews prior to hospital discharge. Our goal was to explore women's (a) decisional influences and prior contraception experience, (b) experience during IPPI and (c) decisional regret. We conducted iterative analysis of interview content until thematic saturation was reached in both groups. Interviewees provided recall pain scores and rated satisfaction with IPPI. RESULTS: We collected 30 pain scores in the no-epidural group and 36 in the epidural group. At both time points, the VAS data exhibited very low pain scores in the epidural group and a uniform distribution in the no-epidural group; standard deviations were large. The majority of women in both groups reported "none-mild" pain on the VRS. Physicians reported minimal difficulty with IUD insertion in most cases. We conducted interviews with 12 women who had an epidural and 9 who did not. Both groups offered similar comments across all domains. Convenience was the primary motivation to undergo IPPI, and women recognized the barriers to obtaining effective contraception remote from delivery. The majority of interviewees, even those with high pain scores, characterized their procedural pain as less than expected, and IUD insertion pain was less than or similar to labor pain. Interviewees' recall pain scores were similar to those reported at the time of IUD insertion. An unanticipated theme that emerged was an ineffective informed consent process; women could not recall most procedural risks or how IPPI was accomplished. All interviewees endorsed IPPI, expressing a high degree of satisfaction; none regretted undergoing the procedure. CONCLUSION: The distributions of our VAS scores did not reveal useful summary statistics in either group. The VRS scores were a more informative representation of women's pain during IPPI; most women reported little pain. Convenience of obtaining highly effective contraception immediately postpartum was the key motivator for undergoing IPPI. All women voiced favorable experiences, even those who had high pain scores. IMPLICATIONS: Women in our study overwhelmingly described less pain than anticipated with IPPI and also reported a high degree of satisfaction. Our study offers valuable patient-centered guidance to inform antenatal contraceptive counseling with respect to IPPI and lays the groundwork for ongoing research towards optimizing women's experiences with the procedure.

Nitrous oxide versus oral sedation for pain management of first-trimester surgical abortion - a randomized study.

OBJECTIVE: The objective of the study was to compare nitrous oxide with oxygen (N2O/O2) to oral hydrocodone/acetaminophen and lorazepam for analgesia during first-trimester surgical abortion. STUDY DESIGN: This double-blind randomized trial assigned women undergoing first-trimester surgical abortion at<11 weeks' gestation to inhaled N2O/O2 vs. oral sedation for pain management. The N2O/O2 group received up to 70:30 ratio during the procedure and placebo pills preprocedure; the oral group received inhaled oxygen during the procedure and oral hydrocodone/acetaminophen 5 mg/325 mg and lorazepam 1 mg preprocedure. The primary outcome was maximum procedural pain, assessed on a 100-mm visual analog scale (VAS; anchors 0=no pain and 100=worst pain) at 2 min postprocedure. A difference of 13 mm on the VAS was considered clinically significant. Satisfaction with pain management was measured on a 100-mm VAS (anchors 0=very unsatisfied, 100=very satisfied). RESULTS: We randomized 140 women, 70 per study arm. Mean age of participants was 26±6.6 years; mean gestational age was 7.3±1.5 weeks. Mean maximum procedure pain scores were 52.5±26.7 and 60.8±24.4 for N2O/O2 and oral groups, respectively (p=.09). Satisfaction with pain management was 69.3±28.4 and 61.5±30.4 for N2O/O2 and oral groups. respectively (p=.15). CONCLUSION: We found no difference in mean procedural pain scores between women assigned to N2O/O2 vs. those assigned to oral sedation for first-trimester surgical abortion. Satisfaction with both options was high. IMPLICATIONS: Women undergoing early surgical abortion experienced no differences in pain and satisfaction between those who used inhaled nitrous oxide and oral sedation. Nitrous oxide, with side effects limited to the duration of inhalation and no need for a ride home, is a viable alternative to oral sedation for first-trimester abortion pain management.

Nitrous oxide for pain management during in-office hysteroscopic sterilization: a randomized controlled trial.

OBJECTIVES: To evaluate whether inhaled nitrous oxide with oxygen (N2O/O2) is associated with less pain compared to oral sedation for pain management during in-office hysteroscopic sterilization. STUDY DESIGN: This double blinded randomized controlled trial enrolled women undergoing in-office hysteroscopic sterilization. All participants received pre-procedure intramuscular ketorolac and a standardized paracervical block. The intervention group also received N2O/O2 via a nasal mask titrated to a maximum 70%:30% mixture by a nurse during the procedure and placebo pills pre-procedure and the active control group received inhaled O2 during the procedure and 5/325 mg hydrocodone/acetaminophen and 1 mg lorazepam pre-procedure. The primary outcome was maximum procedure pain on a 100 mm Visual Analog Scale (VAS with anchors at 0=no pain and 100=worst imaginable pain) assessed 3-5 min post procedure. Thirty women per treatment arm were required to detect a clinically significant pain difference of 20 mm. RESULTS: Seventy-two women, 36 per study arm, were randomized. Mean age of participants was 34.1±5.7 years and mean BMI was 30.1±6.6kg/m2. Mean maximum procedure pain scores were 22.8±27.6 mm and 54.5±32.7 mm for intervention and control groups, respectively (p<.001). Most study participants (97%) stated N2O/O2 should be offered for gynecologic office procedures and 86% would pay for it if not a covered benefit. CONCLUSIONS: N2O/O2 decreased pain with in-office hysteroscopic sterilization compared to oral sedation and is an effective pain management option for this procedure. IMPLICATIONS: Given its safety and favorable side effect profile, N2O/O2 can be used for pain management for in-office hysteroscopic sterilization and adds a safe, easily administered option to currently available strategies.

A randomized controlled trial of nitrous oxide for intrauterine device insertion in nulliparous women.

OBJECTIVE: To evaluate the effectiveness of inhaled nitrous oxide for pain management among nulliparous women undergoing intrauterine device (IUD) insertion. METHODS: A double-blind, randomized controlled trial was conducted among nulliparous women aged 13-45years who underwent IUD insertion at a US center between October 1, 2013, and August 31, 2014. Using a computer-generated randomization sequence, participants were randomly assigned to inhale either oxygen (O2) or a mixture of 50% nitrous oxide and 50% oxygen (N2O/O2) through a nasal mask for 2minutes before insertion. Only the person administering the inhalation agent was aware of group assignment. The primary outcome was maximum pain assessed 2minutes after insertion via a 100-mm visual analog scale. Analyses were by intention to treat. RESULTS: Forty women were assigned to each group. Mean maximum pain score at the time of insertion was 54.3±24.8mm for the N2O/O2 group and 55.3±20.9mm for the O2 group (P=0.86). Adverse effects were reported for 6 (15%) women in the N2O/O2 group and 7 (18%) in the O2 group (P=0.32). CONCLUSION: N2O/O2 did not reduce the pain of IUD insertion among nulliparous women. ClinicalTrials.gov: NCT02391714.

Nitrous oxide for pain management of first trimester surgical abortion -- a randomized controlled pilot study.

OBJECTIVE: The objective was to determine feasibility of a study comparing mean pain scores between women randomized to nitrous oxide/oxygen (NO) versus oxygen+oral analgesics for trimester surgical abortion. STUDY DESIGN: Pilot randomized controlled trial comparing NO (n=10) versus oxygen+oral analgesics (n=10). Feasibility of subject recruitment, and pain and satisfaction scores on a visual analog scale were evaluated. RESULTS: Fifty-seven percent of eligible women participated. Mean pain scores were similar between groups, and mean satisfaction scores were higher for the NO group (77.5 vs. 46.7, P=.048). CONCLUSIONS: The majority of eligible women agreed to participate in this study evaluating an uncommon pain control intervention.

Postpartum contraceptive choices among ethnically diverse women in New Mexico.

OBJECTIVE: The objective of the study was to determine if postpartum contraceptive choices by primiparous women differ by ethnicity. STUDY DESIGN: Retrospective nested cohort study analyzing women's characteristics and contraceptive choice. RESULTS: Of 652 participants, 312 (47.8%) were Hispanic, 287 (44.0%) were non-Hispanic white, and 53 (8.1%) were American Indian (AI). In multivariate analysis, depot medroxyprogesterone acetate (DMPA) and intrauterine device (IUD)/implant choice was related to AI [DMPA: odds ratio (OR) 15.28, confidence interval (CI) 4.49-52.04; IUD/implant: OR 0.46, CI 0.22-0.92] and Hispanic (DMPA: OR 3.44, CI 1.12-10.58) ethnicity. CONCLUSION: DMPA use was higher among Hispanic and AI women and IUD/implant use lower in AI women compared to non-Hispanic white women.

Misoprostol for intrauterine device insertion in nulliparous women: a randomized controlled trial.

OBJECTIVE: To examine the effects of preprocedure misoprostol on intrauterine device (IUD) placement in nulliparous women. STUDY DESIGN: In this randomized controlled double-blind trial at the University of New Mexico reproductive health clinic, nulliparous women requesting an IUD were randomized to 400 mcg of buccal misoprostol or placebo 2-8 hours before insertion. Primary outcomes included pain on a 10-cm visual analog scale and women's perception of the value of delaying insertion for an effective medication. Provider ease of insertion and need for adjunctive insertion measures were also assessed, on a visual analog scale. Participants indicated maximum pain after IUD insertion, pain level they would tolerate to avoid delay in IUD insertion, and preference for IUD insertion without delay if an effective medication was available. RESULTS: Of 85 women enrolled, 3 were ineligible; 42 were randomized to misoprostol and 40 to placebo. There were no differences between groups in worst insertion pain, (5.8 ± 2.0 vs 5.9 ± 2.0, P = .94), provider ease of insertion (2.2 ± 2.2 vs 2.5 ± 2.2; P = .54) or adjunctive measures (14% vs 25%; P = .27). The groups were willing to tolerate the same mean pain (4.9 ± 2.5 vs 5.7 ± 2.4, P = .18) to avoid waiting for medication. The majority of women (85%) preferred to wait for an effective medication. CONCLUSION: Misoprostol for nulliparous women did not decrease pain or improve the ease of insertion of an IUD. Most women were willing to wait for a medication that decreases pain, indicating a need to pursue alternatives for pain control with IUD insertion.

The role of physical examination in diagnosing common causes of vaginitis: a prospective study.

OBJECTIVE: We evaluated agreement in diagnoses for bacterial vaginosis (BV), Trichomonas vaginalis (TV) and vulvovaginal candidiasis (VVC) between clinicians examining the patient and performing diagnostic tests versus a clinician with access only to the patient's history and diagnostic findings from self-obtained vaginal swabs (SOVS). DESIGN: Women presenting with vaginal discharge to a sexually transmitted infections clinic provided SOVS for evaluation and completed the study and qualitative questionnaires. A clinician then obtained a history and performed speculum and bimanual examinations. Participants' history and diagnostic test results from SOVS were provided to a masked non-examining clinician who rendered independent diagnoses. Overall agreement in diagnoses and κ statistics was calculated. RESULTS: The prevalence of infections among the 197 participants was 63.4% (BV), 19% (TV) and 14% (VVC). The per cent agreement between the examining and non-examining clinician for the diagnoses of BV was 68.5%, 90.9% for TV and 91.9% for VVC. Of the 105 women diagnosed with BV by the examining clinician, 34 (32%) were missed by the non-examining clinician. The non-examining clinician missed 13 (48%) of 27 women and 12 (34%) of 35 women treated for VVC and TV, respectively. Four women who all presented with abdominal pain were diagnosed with pelvic inflammatory disease. CONCLUSIONS: Tests from SOVS and history alone cannot be used to adequately diagnose BV, TV and VVC in women presenting with symptomatic vaginal discharge. Cost benefits from eliminating the speculum examination and using only tests from SOVS may be negated by long-term costs of mistreatment.

Immediate placement of intrauterine devices after first and second trimester pregnancy termination.

BACKGROUND: We reviewed our experience with intrauterine device (IUD) placement after surgical abortion up to 20 weeks' gestation. STUDY DESIGN: Women presenting for elective abortion between January 2004 and March 2009 who requested an IUD were included in this retrospective review. RESULTS: Of 308 women requesting postabortion IUD placement, 221 (72%) planned insertion at the time of abortion (immediate group) and 87 (28%) planned insertion at their postoperative visit (interval group). IUDs were placed in 96% of the immediate group and in 23% of the interval group (212/221 vs. 20/87; p<.0001). Failure to return for placement was the most common reason for noninsertion in the interval group (60/87=69%). Follow-up information was obtained for 56% of patients and was documented a median of 137 days postabortion (range 3-1594 days). There was no difference in complication rates between groups. Expulsion rates were 3% and 0% in the immediate and interval groups, respectively (6/212 vs. 0/20; p=.4). Considering only those with documented follow-up after immediate insertion (119), there was a nonsignificant trend towards increased expulsion with placement after second vs. first trimester abortion (4/54=7% vs. 2/65=2%; p=.3). When analyzing the 172 subjects with documented follow-up, those planning immediate insertion were more likely to have an IUD in situ at the last contact than those planning later insertion (84/124=68% vs. 20/48=42%; p=.002). CONCLUSION: Immediate postabortion IUD insertion is safe and effective. Given the low rate of return for interval insertion, immediate placement may be preferable.

Predictors and perception of pain in women undergoing first trimester surgical abortion.

BACKGROUND: The aim of the study was to evaluate pain and predictors of pain in women undergoing electric (EVA) or manual vacuum aspiration (MVA) for first trimester surgical abortions and to examine how perceptions of pain differ among participants, advocates (participant support person) and physicians. STUDY DESIGN: In this randomized controlled study, women presenting for first trimester abortion underwent standardized EVA or MVA. Participants completed questionnaires, visual analog scales (VAS) and Likert scales for pain. Logistic and linear regression models were used to analyze the data. RESULTS: Nonwhite women and women who preoperatively expected more pain reported higher procedure-related pain scores. Vacuum source, previous history of abortion, comfort with decision to have an abortion and partner involvement did not affect participant pain scores. In the multivariable analyses, no single factor predicted procedure-associated pain. The advocates perceived that more educated women had less pain. Physicians felt longer procedures and a woman's fear of pelvic examinations caused more pain. Physicians believed women had less pain than the participants reported themselves (p<.001). Only physicians thought that EVA was less painful than MVA (p<.01). CONCLUSION: Distinct factors other than vacuum source affect the perception of abortion-related pain. Understanding these factors may help inform counseling strategies aimed at ameliorating pain perception during first trimester abortions.

The role of speculum and bimanual examinations when evaluating attendees at a sexually transmitted diseases clinic.

BACKGROUND: With the advent of molecular techniques, self-collected specimens without a clinician's examination are often adequate to detect common genital infections. OBJECTIVE: To evaluate the additional information that speculum and bimanual examinations provides clinicians in the routine evaluation of genital infections among attendees of a sexually transmitted disease (STD) clinic. METHODS: Cross-sectional study from a database of all visit records to two STD clinics in Baltimore between 1996 and 2002. Women were stratified on the basis of reason for visit. Proportional and likelihood ratio estimates of the speculum examination in detecting clinically relevant cervicovaginal lesions (leading to a diagnosis of other infections or outside referral for further management) and bimanual examination in detecting abnormalities (leading to a diagnosis of pelvic inflammatory disease or referral) are presented. RESULTS: 15 918 of 21 703 records were included: 12 073 were symptomatic (SYM; discharge, rash, abdominal pain, dysuria, genital irritation or odour), 1676 were asymptomatic contacts of an infected partner (CON) and 2169 were asymptomatic and presented for checkup (ASYM). The median age was 26 years; 94% were black. 11.8% of SYM, 4.6% of CON and 3.9% of ASYM patients had clinically meaningful lesions detected on speculum examination. The bimanual examination detected clinically relevant abnormalities in 6.5% of SYM, 0.8% of CON and 0.6% of ASYM patients. CONCLUSION: Symptomatic women are most likely to benefit from speculum and bimanual examinations. However, their yield in evaluating asymptomatic women is low. Prospective studies are needed to determine whether eliminating speculum and bimanual examinations in a subset of women would offer an operational advantage without compromising patient safety.

Cost-effectiveness of treatments for dysfunctional uterine bleeding in women who need contraception.

OBJECTIVE: This study aims to compare the cost-effectiveness of oral contraceptives (OCs), the levonorgestrel-releasing intrauterine system (LNG-IUS) and surgical management in treating dysfunctional uterine bleeding (DUB) in women not desiring additional children. METHOD: A Markov model was constructed from the perspective of the health services payers for a 5-year period. Treatment costs, DUB treatment success rates and contraception success rates were obtained through a literature review. RESULTS: In women not responding to an initial trial of OCs, surgical management was more effective than the LNG-IUS (95.5% vs. 92%) but at higher cost (US$4853 vs. US$2796 per woman). Among responders to OCs, continuing treatment with the LNG-IUS instead of OCs was more effective (92% vs. 90.4%) and less expensive (US$2796 vs. US$4711). For women naïve to medical therapy, the LNG-IUS and OCs had similar effectiveness, but cost for the LNG-IUS was lower (US$2796 vs. US$4895). In all scenarios, surgery followed if medical therapy failed; rates of primary method failure were 62.5% with OCs and 34% with the LNG-IUS at 12 months. CONCLUSIONS: Treatment strategies employing the LNG-IUS are the most cost-effective in managing DUB, regardless of whether a woman has previously tried OC therapy.