Perioperative pregnancy interval, contraceptive counseling experiences, and contraceptive use in women undergoing bariatric surgery.

BACKGROUND: Reproductive-aged women represent about half of those undergoing bariatric surgery in the United States. Obstetric and bariatric professional societies recommend that women avoid pregnancy for 12-18 months postoperatively due to concern for increased pregnancy risks, and that providers should counsel women about these recommendations and their contraceptive options. However, knowledge about women's experience with perioperative counseling and postoperative contraceptive use is limited. OBJECTIVE: We sought to: (1) determine prevalence of perioperative contraceptive and pregnancy interval discussions among women who have recently undergone bariatric surgery; and (2) describe postoperative contraceptive use within the first year of surgery in this population. STUDY DESIGN: We performed a cross-sectional study of US women, aged 18-45 years and recruited through Facebook, who underwent bariatric surgery within the last 24 months. RESULTS: We enrolled 363 geographically diverse women. Three-quarters recalled perioperative pregnancy or contraceptive discussions, the majority with a bariatric provider. Half felt it was "very important" to discuss these issues perioperatively, and 41% of those who reported discussions wished they had had more. Of the 66% of women who reported using contraception in the first 12 months postoperatively, 27% used oral contraceptives and 26% used an intrauterine device. One third of contraceptive users who had undergone Roux-en-Y gastric bypass, a combined restrictive-malabsorptive procedure, were using oral contraceptives. Perioperative contraceptive or pregnancy discussions were independently associated with increased postoperative contraceptive use (odds ratios, 2.5; 95% confidence interval, 1.5-4.3, P < .001). CONCLUSION: A substantial proportion of women who had undergone bariatric surgery reported having had no perioperative pregnancy or contraception counseling, and many women who had felt the discussions were insufficient. Those who had had perioperative discussions were more likely to use contraception postoperatively. Reproductive-aged women should be routinely counseled perioperatively about pregnancy and contraception in the context of their reproductive desires, so they can make informed decisions about perioperative pregnancy prevention and contraceptive method use.

Medication abortion failure in women with and without previous cesarean delivery.

OBJECTIVE: To investigate the association between previous cesarean delivery and medication abortion failure and the association between parity and failure. METHODS: Data were abstracted from 2035 consecutive charts of women who underwent medication abortion in 2011. All women were at 63 days gestation or less and received mifepristone 200mg orally and misoprostol 800 mcg buccally. We used multivariate logistic regression to assess the relationship between failure, defined as requiring either curettage or additional medication, and prior cesarean delivery. We also examined the relationship between failure and parity. RESULTS: Follow-up was available on 1609 (79%) patients. Overall, 4.5% of patients experienced failure. Neither cesarean delivery nor parity was associated with failure; 6.5% of women with prior cesarean delivery experienced failure, compared to 3.7% of nulliparous women [adjusted odds ratio (aOR), 1.79, 95% confidence interval (CI), 0.83-3.87]. With regard to parity, 4.7% of women with two or more previous births experienced failure, compared to 3.7% of nulliparous women (aOR, 1.07, 95% CI, 0.54-2.14). CONCLUSION: We did not find significant associations between prior cesarean delivery and failure or parity and failure. A previous study of patients who had received a less effective regimen reported significant associations between cesarean delivery and failure and parity and failure. While our results do not rule out the possibility of modest associations due to our limited statistical power, they are reassuring relative to previous findings. IMPLICATIONS: Our results suggest that if there are differences in women's odds of medication abortion failure by obstetric history, such differences are unlikely to be large. Providers and patients may factor this information into decision making about methods of pregnancy termination.

Immediate versus delayed initiation of the contraceptive patch after abortion: a randomized trial.

BACKGROUND: Immediate start of the contraceptive patch has not been studied in women after surgical abortion. STUDY DESIGN: Women presenting for surgical abortion who had chosen the transdermal patch for contraception were randomized to either delayed start of the patch (beginning the Sunday after their abortion) or immediate start (directly observed application of the patch in the clinic). Subjects were contacted at 2 and 6 months to assess contraceptive use. RESULTS: Two hundred ninety-eight women were randomized, and the follow-up rate was 71% at 2 months and 53% at 6 months. Method continuation did not differ by timing of initiation. At 2 months, 71% in the delayed-start group and 74% in the immediate-start group were using the patch [p=.6, with a difference of 3.1%, 95% confidence interval (CI)=-17.2% to +11.2%]. At 6 months, 55% in the delayed-start group and 43% in the immediate-start group were using the patch (p=.13, with a difference of 11.9%, 95% CI=-19.2% to +34%). CONCLUSION: Immediate initiation of the contraceptive patch after surgical abortion was not associated with increased use of patch at 2 or 6 months.

Medical liability insurance as a barrier to the provision of abortion services in family medicine.

Family physicians who wish to provide abortions have been subject to both denial of coverage by medical liability insurers and the imposition of large premium increases. These policy decisions by insurance companies raise questions about the role of family physicians in abortion care and about the autonomy of medical specialties in defining their scope of practice. We review the issues specific to abortion services in the primary care setting and examine the broader implications for the medical profession. Finally, we review how advocacy and improved regulation of the insurance industry could help to ensure that clinicians who are trained and willing to provide services to their patients are not limited by the decisions of medical liability insurers.