Potential demand for and access to medication abortion among North Carolina college students.

OBJECTIVE: To estimate demand for medication abortion (MAB) among North Carolina (NC) college students and describe access to nearest clinics offering MAB to each campus. METHODS: We calculated demand using 2019-2020 campus demographics and NC abortion statistics. We used a mystery client technique to gather MAB cost and appointment wait times at the closest clinics and calculated travel distances and times. RESULTS: We estimated that 2,517 NC students seek MAB annually. Twenty-one clinics were closest to NC's 111 colleges and universities, including five in neighboring states. Mean cost was $450, with an average wait time of six days to appointment. The average round-trip travel distance was 58 miles and time to the nearest clinic was 84 min by car. CONCLUSIONS: Many NC college students likely obtain MAB every year and face high costs, long wait times and distances to care, which has likely worsened after the overturning of Roe v. Wade.

Single-Visit Long-Acting Reversible Contraception Initiation Among Adolescents Before and During COVID-19.

PURPOSE: Single-visit long-acting reversible contraception (LARC) is cost-effective and convenient. Our objective was to compare incidence of single-visit LARC placement and associated factors during the year before the COVID-19 pandemic (March 15, 2020) and the first year of the pandemic. METHODS: This retrospective cohort study analyzed electronic health records from a large healthcare system. Eligible adolescents were aged 10-19 years and received outpatient LARC from March 15, 2019 to March 14, 2021. Logistic regression models determined the relationship of patient and provider characteristics on single-visit LARC before and during COVID-19. RESULTS: One thousand six adolescents initiated LARC during the study period. Fewer adolescents received single-visit LARC during COVID-19 (289/506, 57.1%) compared to before (315/500, 63.0%), although changes in odds of single-visit LARC were not statistically significant. Concordance between county of patient residence and the location of the LARC placement facility was associated with single-visit LARC before (adjusted odds ratio [aOR] = 2.75) and during (aOR = 1.74) the pandemic (both p < .05). During the pandemic, a few factors were associated with reduced odds of single-visit LARC: (1) public insurance (aOR = 0.49, p < .01), (2) nonobstetricians/nongynecologists providers (pediatrics [aOR = 0.35, p < .01], family medicine [aOR = 0.53, p < .01], or internal medicine [aOR = 0.14, p < .05]), and (3) advanced practice practitioners (aOR = 0.49, p < .01). DISCUSSION: Incidence of single-visit LARC was similar before and during the pandemic. Certain factors were associated with lower odds of single-visit LARC insertion, suggesting differential access during the pandemic for subgroups of adolescents. Our findings may guide policy and programmatic interventions to improve access to single-visit LARC for all adolescent populations.

Single-visit insertion of long-acting reversible contraception in a single health system.

OBJECTIVE: To identify patient and practice characteristics associated with single-visit placement of long-acting reversible contraception (LARC) across the University of North Carolina Health system. STUDY DESIGN: We conducted a retrospective observational study using existing electronic health records. We abstracted data from charts of individuals ages 15-50 years who received a LARC device between March 15, 2019, and March 14, 2021. Our primary outcome was whether a patient received LARC at one, or after multiple, outpatient visits. We used descriptive statistics to examine patient, clinician, and practice characteristics. We used bivariate analysis and generalized estimating equation to examine relationships between characteristics and single-visit LARC receipt. RESULTS: Most of the 4599 individuals received care at obstetrics and gynecology clinics (3411/4599; 74%), and received their LARC device in a single visit (3163/4599; 69%). More intrauterine devices (3151) were placed than implants (1448). The adjusted odds of receiving a LARC in a single visit was highest for those who self-paid (aOR (adjusted odds ratio) 1.83, 1.19-2.82) and those who received an implant (aOR 1.25, 1.07-1.46). Patients seen by advanced practice practitioners (aOR 0.67, 0.56-0.80) or by an internal medicine specialty clinician (aOR 0.13, 0.00-0.35) had lower odds of receiving a single-visit LARC compared to those seen by a specialist obstetrician-gynecologist physician. CONCLUSION: Most single-visit LARC placements were performed by clinicians in obstetrician-gynecologist specialty practices. IMPLICATIONS: Among individuals seeking long-acting reversible contraceptives from clinics in a single health system in North Carolina, most received a device at a single visit and most single-visit insertions were done by an obstetrician-gynecologist.

Unfulfilled Requests for Postpartum Tubal Ligation at a Southern Tertiary Care Center.

BACKGROUND Nationally, multiple barriers lead only 50% of women who request postpartum tubal ligation to receive it prior to discharge. We aimed to identify characteristics associated with unfulfilled requests for postpartum tubal ligation at a tertiary medical center in the South.METHODS We conducted a retrospective chart review of all women delivering a live infant with a documented desire for postpartum sterilization between September 1, 2018, and November 30, 2018. The primary outcome was receipt of postpartum sterilization prior to discharge. We used chi-square and Mann Whitney U tests for descriptive analyses.RESULTS One thousand seventy-two women delivered a live infant at our institution during our sampling frame. One hundred twenty-four had a documented desire for postpartum sterilization (124/1072, 12%). Eighty-one women (81/124, 65%) received their postpartum sterilization and 43 women (43/124, 35%) did not. Women who delivered by cesarean were more likely to receive their postpartum sterilization (63/68; 93%) than if they delivered vaginally (18/56; 32%) (P < .001). Lack of valid Medicaid consent (P = .006) was associated with unfulfilled requests for postpartum sterilization following vaginal delivery while BMI > 40 (P = .158) approached significance.LIMITATIONS Our sample is small and from a single institution. Additionally, the specific reason for tubal ligation nonfulfillment was often not documented.CONCLUSIONS In this Southern institution, women delivering vaginally, those without a valid Medicaid consent form, and women with BMI > 40 were less likely to receive desired postpartum sterilization. Multipronged process changes are needed to fulfill patients' sterilization requests.

Comparing Website Identification for Crisis Pregnancy Centers and Abortion Clinics.

BACKGROUND: Crisis pregnancy centers (CPCs) seeking to dissuade women from abortion often appear in Internet searches for abortion clinics. We aimed to assess whether women can use screenshots from real websites to differentiate between CPCs and abortion clinics. METHODS: We conducted a cross-sectional, nationally representative online study of English- and Spanish-speaking women aged 18-49 years in the United States. We presented participants with screenshots from five CPCs and five abortion clinic websites and asked if they thought an abortion could be obtained at that center. We scored correct answers based on clinic type. Outcomes included ability to correctly identify CPCs and abortion clinics as well as risk factors for misidentification. The survey also included five questions about common abortion myths and a validated health literacy assessment. RESULTS: We contacted 2,223 women, of whom 1,057 (48%) completed the survey and 1,044 (47%) were included in the analysis. The median score for correctly identifying CPCs as facilities not performing abortion was 2 out of 5 (Q1: 0, Q3: 4). The median score for correctly identifying abortion clinics as facilities performing abortion was 5 out of 5 (Q1: 3, Q3: 5). Those less likely to endorse abortion myths had higher odds of correctly identifying CPCs (adjusted odds ratio, 2.43; 95% confidence interval, 1.78-3.32). A low health literacy score was associated with decreased odds of correct identification of CPCs (adjusted odds ratio, 0.39; 95% confidence interval, 0.25-0.59). CONCLUSIONS: Websites of CPCs were more difficult for women to correctly identify than those of abortion clinics. Women with limited knowledge about abortion and low health literacy may be particularly susceptible to misidentification of CPC websites.

Pregnancy Medicaid Improvements in a Nonexpansion State After the Affordable Care Act.

One-half of women in the United States use Medicaid during pregnancy. Women living in states that did not expand Medicaid under the Patient Protection and Affordable Care Act (ACA) are at risk of losing coverage post partum. We analyzed Medicaid claims and vital statistics for the state of North Carolina for the period 2011 to 2017. North Carolina did not expand Medicaid but did alter Medicaid enrollment to meet ACA requirements. After implementation, enrollment in full Medicaid during pregnancy almost doubled, and enrollment in Medicaid for pregnant women decreased. Full Medicaid offers more comprehensive coverage and does not expire at 60 days post partum, allowing for access to crucial preventive health services including contraception and primary care.

Frequency and characteristics associated with opportunistic salpingectomy at cesarean delivery: A retrospective chart review.

OBJECTIVES: To identify the frequency and characteristics associated with total salpingectomy (TS) versus occlusion or partial salpingectomy (PS) at the time of cesarean delivery. STUDY DESIGN: We performed a retrospective chart review of cesarean deliveries with a concurrent permanent contraception procedure, from July 1, 2014 to June 30, 2019 at 2 hospitals (community hospital and tertiary care academic center) within a single healthcare system. We assessed the proportion of TS versus PS at cesarean, and secondarily compared operative times between the 2 procedures. RESULTS: We identified 2110 procedures during the 5-year period. Surgeons performed TS in 302 (14%, 95% confidence interval [CI] 13%-16%) cases, and the annual rate varied from 14% to 18% over the study period (p = 0.14). Factors associated with increased likelihood of TS rather than PS included public insurance/self-pay (adjusted odds ratio, aOR 2.8, 95% CI 2.0-4.1), delivery at the community hospital (aOR 4.8, 95% CI 3.0-7.7), parity of 5 or more (aOR 2.2, 95% CI 1.1-4.4), and presence of an obstetrician/gynecologist for cesarean delivery (aOR 2.9, 95% CI 1.6-5.4). The total operative time for TS and PS differed at the academic center (90 vs 68 minutes, p < 0.001) but not at the community hospital (55 vs 54 minutes, p = 0.5). CONCLUSIONS: This study highlights provider and institutional characteristics associated with TS compared to PS at the time of cesarean delivery, which may inform future programs aimed at increasing utilization of TS at cesarean delivery. IMPLICATIONS: Access to TS at the time of cesarean delivery may provide pregnant women with a very effective permanent contraception method at a convenient time of concurrent cesarean. This study identifies patient factors that may influence access to TS as part of obstetrical care.

Women's knowledge of their state's abortion regulations. A national survey.

OBJECTIVES: States vary significantly in their regulation of abortion. Misinformation about abortion is pervasive and propagated by state-mandated scripts that contain abortion myths. We sought to investigate women's knowledge of abortion laws in their state. Our secondary objective was to describe women's ability to discern myths about abortion from facts about abortion. STUDY DESIGN: This was a cross-sectional study of English- and Spanish-speaking women aged 18-49 in the United States. We enrolled members of the GfK KnowledgePanel, a probability-based, nationally-representative online sample. Our primary outcome was the proportion of correct answers to 12 questions about laws regulating abortion in a respondent's state. We asked five questions about common abortion myths. We used descriptive statistics to characterize performance on these measures and bivariate and multivariate modeling to identify risk factors for poor knowledge of state abortion laws. RESULTS: Of 2223 women contacted, 1057 (48%) completed the survey. The mean proportion of correct answers to 12 law questions was 18% (95% CI 17-20%). For three of five assessed myths, women endorsed myths about abortion over facts. Those who believe abortion should be illegal (aOR 2.18, CI 1.40-3.37), and those living in states with neutral or hostile state policies toward abortion (neutral aOR 1.99, CI 1.34-2.97; hostile aOR 1.6, CI 1.07-2.36) were at increased odds of poor law knowledge. CONCLUSIONS: Women had low levels of knowledge about state abortion laws and commonly endorse abortion myths. Women's knowledge of their state's abortion laws was associated with personal views about abortion and their state policy environment. IMPLICATIONS: Supporters of reproductive rights can use these results to show policy makers that their constituents are unlikely to know about laws being passed that may profoundly affect them. These findings underscore the potential benefit in correcting widely-held, medically-inaccurate beliefs about abortion so opinions about laws can be based on fact.

The Impact of a 72-hour Waiting Period on Women's Access to Abortion Care at a Hospital-Based Clinic in North Carolina.

BACKGROUND In 2015, North Carolina became the 5th state to pass legislation requiring women to undergo state-mandated counseling 72 hours prior to abortion. Whether this legislation has changed the timing of abortion decision-making or receipt of care is not known.METHODS This is a cross-sectional study using anonymous survey data from women presenting for abortion at a hospital-based abortion clinic in North Carolina. Data were collected for 8 weeks immediately before and after implementation of the new waiting period.RESULTS 26/48 (54%) of eligible patients participated. More than half (56%) of women made their abortion decision relatively quickly (less than or equal to 3 days), but had a median time-to-care of almost a week.LIMITATIONS This small study is the 1st recent evaluation of abortion decision-making and receipt of care immediately before and after implementation of a 72-hour waiting period in a Southern state. Only women presenting for care at a single hospital-based clinic were surveyed. Data were self-reported.CONCLUSION In our clinical setting, most women decided to have an abortion quickly but still waited 10-15 days before receiving care. Extended waiting periods provide no medical benefits and the potential for harm and delay of care remains.

Risk-Reducing Salpingectomy Versus Standard Tubal Sterilization: Lessons From Offering Women Options for Interval Sterilization.

OBJECTIVES: In women receiving sterilization, the removal of the entire fallopian tube, a procedure referred to as a risk-reducing salpingectomy (RRS), reduces subsequent ovarian cancer risk compared with standard tubal sterilization procedures. There are limited data on which surgical procedure women will choose when educated about the benefits of an RRS. Our objective was to study the proportion of women desiring sterilization that would choose an RRS. METHODS: This cohort study included women 30 years of age and older with a living biological child who requested laparoscopic sterilization at a tertiary academic hospital. Participants were given a decision aid and offered an RRS or a standard tubal sterilization procedure with titanium clips. The primary outcome was to determine the proportion of women who would choose an RRS. Other outcomes included estimated blood loss and operative time, which was compared between groups, along with complications. RESULTS: Fourteen of the 18 (78%) women who participated in our study chose RRS. Estimated blood loss and operating time were similar among women who underwent RRS and standard tubal sterilizations. There were no significant complications in either group. The study was ended early based on emerging data and a change in national practice patterns. CONCLUSIONS: Because of the elective nature of sterilization and the complexities of cancer risk reduction, a patient-centered approach is beneficial for sterilization counseling. Our results support offering RRS as an alternative to standard tubal sterilization.

What Is New in Global Women's Health? (Part 2): Best Articles From the Past Year.

This month we focus on current research in women's global health. Drs. Stuart and Ramsey discuss five recent publications, which are concluded with a "bottom line" that is a take-home message. A complete reference for each can be found in on this page along with direct links to abstracts.

Interval Female Sterilization.

Female sterilization is relied on by nearly one in three women aged 35-44 years in the United States. Sterilization procedures are among the most common procedures that obstetrician-gynecologists perform. The most frequent sterilization procedures include postpartum tubal ligation, laparoscopic tubal disruption or salpingectomy, and hysteroscopic tubal occlusion. The informed consent process for sterilization is crucial and requires shared decision-making between the patient and the health care provider. Counseling should include the specific risks and benefits of the specific surgical approaches. Additionally, women should be counseled on the alternatives to sterilization, including intrauterine contraceptives and subdermal contraceptive implants. Complications, including unplanned pregnancy after successful female sterilization, are rare. The objectives of this Clinical Expert Series are to describe the epidemiology of female sterilization, access to postpartum sterilization, advances in interval sterilization techniques, and clinical considerations in caring for women requesting sterilization.

What Is New in Global Women's Health? (Part 1): Best Articles From the Past Year.

This month we focus on current research in global women's health. Drs. Ramsey and Stuart discuss four recent publications, which are concluded with a "bottom line" that is a take-home message. A complete reference for each can be found in on this page along with direct links to abstracts.

Amenorrhea rates and predictors during 1 year of levonorgestrel 52 mg intrauterine system use.

OBJECTIVE: The objective was to evaluate amenorrhea patterns and predictors of amenorrhea during the first year after levonorgestrel 52 mg intrauterine system (IUS) placement. STUDY DESIGN: This cohort analysis includes 1714 nulliparous and parous women who received a Liletta® levonorgestrel 52 mg IUS in a multicenter trial to evaluate efficacy and safety for up to 8 years. Participants maintained a daily diary with bleeding information. We assessed bleeding patterns in 90-day intervals; amenorrhea was defined as no bleeding or spotting in the preceding 90 days. We employed multivariable regression to identify predictors of amenorrhea at 12 months. The predictor analysis only included women not using a levonorgestrel IUS in the month prior to study enrollment. RESULTS: In the month before enrollment, 148 and 1566 women, respectively, had used and not used a levonorgestrel IUS. Prior users averaged 50±19 months of use before IUS placement; 38.4% of these women reported amenorrhea at 12 months. Amenorrhea rates for non-prior-users at 3, 6, 9 and 12 months were 0.2%, 9.1%, 17.2% and 16.9%, respectively. During the first 12 months, 29 (1.7%) women discontinued for bleeding irregularities; no women discontinued for amenorrhea. The only significant predictor of amenorrhea at 12 months was self-reported baseline duration of menstrual flow of fewer than 7 days vs. 7 or more days (18.2% vs. 5.2%, adjusted odds ratio 3.70 [1.69, 8.07]). We found no relationships between 12-month amenorrhea rates and age, parity, race, body mass index, baseline flow intensity or hormonal contraception use immediately prior to IUS placement. CONCLUSIONS: Amenorrhea rates during the first year of levonorgestrel 52 mg IUS use are similar at 9 and 12 months. Amenorrhea at 12 months is most common among women with shorter baseline duration of menstrual flow. IMPLICATIONS STATEMENT: This information provides more data for clinicians when counseling women about amenorrhea expectations, especially since women seeking a levonorgestrel 52 mg IUS for contraception are different than women desiring treatment for heavy menstrual bleeding. Amenorrhea at 12 months is most common among women with shorter baseline duration of menstrual flow.

Medical abortion reversal: science and politics meet.

Medical abortion is a safe, effective, and acceptable option for patients seeking an early nonsurgical abortion. In 2014, medical abortion accounted for nearly one third (31%) of all abortions performed in the United States. State-level attempts to restrict reproductive and sexual health have recently included bills that require physicians to inform women that a medical abortion is reversible. In this commentary, we will review the history, current evidence-based regimen, and regulation of medical abortion. We will then examine current proposed and existing abortion reversal legislation. The objective of this commentary is to ensure physicians are armed with rigorous evidence to inform patients, communities, and policy makers about the safety of medical abortion. Furthermore, given the current paucity of evidence for medical abortion reversal, physicians and policy makers can dispel bad science and misinformation and advocate against medical abortion reversal legislation.

Management of Intrauterine Contraception in Early Pregnancy.

OBJECTIVES: Women with rare intrauterine contraception (IUC) failures are advised to have their IUC removed because of the risk of poor obstetric outcomes with a retained IUC. Specifics regarding IUC removal in early pregnancy including techniques for removal, rates of success, and immediate pregnancy outcomes following removal are not well described, however. The objective of this study was to identify women with an IUC in early pregnancy examined at a tertiary care center with the primary objective of describing IUC removal attempts, IUC removal successes, and pregnancy outcomes at 20 weeks following IUC removal. METHODS: Case series of women with concurrent IUC and early pregnancy who presented to a tertiary care ultrasound center by 12 weeks' gestation. RESULTS: A total of 3116 women had an early pregnancy ultrasound during the study period. Nineteen (19/3116, 0.61%) women underwent ultrasounds that identified a pregnancy before 12 weeks and an IUC in the uterus. A copper IUC was identified in 11 women (11/19, 58%) on their first ultrasound, and a levonogestrel IUC was identified in 5 women (5/19, 26%). Seventeen (17/19, 88%) women attempted to remove their IUC; 11 of 69 (69%) were successfully removed on the first attempt. Fourteen (14/19; 74%) women with an IUC examined by 12 weeks' gestation had an ongoing pregnancy at 20 weeks compared with 1782 (1782/2678, 67%; P = 0.209) women without an IUC. CONCLUSIONS: Pregnancy with IUC is rare. Among the 19 women who were found to have an in situ IUC and early pregnancy, most had a successful IUC removal and had an ongoing pregnancy at 20 weeks' gestation. In our case series, IUC removal in the first trimester was a straightforward procedure and likely successful.

Dual Method Use among Postpartum HIV-Infected and HIV-Uninfected Malawian Women: A Prospective Cohort Study.

Dual method use, use of condoms plus another effective contraceptive method, is important in settings with high rates of unintended pregnancy and HIV infection. We evaluated the association of HIV status with dual method use in a cohort of postpartum women. Women completed baseline surveys in the postpartum ward and telephone surveys about contraceptive use 3, 6, and 12 months later. Nonpregnant women who completed at least one follow-up survey were eligible for this secondary analysis. Prevalence ratios were calculated using generalized estimating equations. Of the 511 sexually active women who completed a follow-up survey, condom use increased from 17.6% to 27.7% and nonbarrier contraceptive use increased from 73.8% to 87.6% from 3 to 12 months after delivery. Dual method use increased from 1.0% to 18.9% at 3 to 12 months after delivery. Dual method use was negligible and comparable between HIV-infected and HIV-uninfected women at 3 months but significantly higher among HIV-infected women at 6 months (APR = 3.9, 95% CI 2.2, 7.1) and 12 months (APR = 2.7, 95% CI 1.7, 4.3). Dual method use was low but largely driven by condom use among HIV-infected women at 6 and 12 months after delivery.

Contraception Insurance Coverage and Receipt of Long-Acting Reversible Contraception or Depot Medroxyprogesterone Acetate on the Day of Abortion.

OBJECTIVE: To evaluate whether contraceptive insurance coverage for women who present for an abortion is associated with obtaining long-acting reversible contraception or depot medroxyprogesterone acetate (DMPA) on the day the abortion is completed. METHODS: We conducted a prospective cohort study of women presenting for medical or surgical abortion at a single health center in North Carolina. Eligible women were 18 years or older and fluent in English or Spanish. Data were from participant questionnaires, medical charts, and financial records. Our main exposure was whether the woman had insurance coverage for contraception at clinic intake. Our primary outcome was receiving DMPA, an intrauterine device, or a contraceptive subdermal implant on the same day of their surgical abortion or at the visit that determined their medication abortion was complete. We used univariable, bivariable, and multivariable analysis to report our findings. RESULTS: Five hundred seventy-five women enrolled in our cohort between September 2015 and April 2016. One hundred twenty-eight (22%) had insurance coverage and 447 (78%) did not. In the group with insurance coverage for contraception, 38% (49/128) received a long-acting reversible contraception method or DMPA compared with 7% (33/447) in the group without insurance coverage for contraception. After adjusting for confounding, women with contraceptive coverage were more than five times as likely to receive immediate postabortion contraception with one of these methods compared with women without coverage (relative risk 5.6, 95% confidence interval 3.8-8.3). CONCLUSION: Women with contraceptive insurance coverage on the day of their abortion were more likely to leave the abortion clinic with an intrauterine device or implant in place or receive DMPA injection compared with women without coverage.

Patterns of Contraceptive Adoption, Continuation, and Switching after Delivery among Malawian Women.

Women who report use of postpartum family planning may not continue their initial method or use it consistently. Understanding the patterns of method uptake, discontinuation, and switching among women after delivery is important to promote uptake and continuation of effective methods of contraception. This is a secondary analysis of 634 Malawian women enrolled into a prospective cohort study after delivery. They completed baseline surveys upon enrollment and follow-up telephone surveys 3, 6, and 12 months post-delivery. Women were included in this analysis if they had completed at least the 3- and 6-month post-delivery surveys. Descriptive statistics were used to assess contraceptive method mix and patterns of switching, whereas Pearson's χ2 tests were used for bivariable analyses to compare characteristics of women who continued and discontinued their initial post-delivery contraceptive method. Among the 479 women included in this analysis, the use of abstinence/traditional methods decreased and the use of long-acting and permanent methods (LAPM) increased over time. Almost half (47%) discontinued the contraceptive method reported at 3-months post-delivery; women using injectables or LAPM at 3-months post-delivery were significantly more likely to continue their method than those using non-modern methods (p<0.001). Of the 216 women who switched methods, 82% switched to a more or equally effective method. The change in contraceptive method mix and high rate of contraceptive switching in the first 12 months postpartum highlights a need to assist women in accessing effective contraceptives soon after delivery.