Impact of previous gestational diabetes management on perinatal outcomes in subsequent pregnancies affected by gestational diabetes mellitus.

OBJECTIVE: To determine the impact of prior gestational diabetes mellitus (GDM) on perinatal outcomes in a subsequent GDM pregnancy. METHODS: This retrospective cohort study included 544 multiparous patients with two consecutive pregnancies between 2012-2019, where the second (index) pregnancy was affected by GDM. The primary exposure was prior GDM diagnosis, categorized into medical and dietary management. The primary outcome was a composite including need for pharmacotherapy, large-for-gestational age, or neonatal hypoglycemia. Adjusted odds ratios (aOR) were calculated using multivariable logistic regression controlling for maternal age, pre-pregnancy body mass index, and gestational age at GDM diagnosis in the index pregnancy. RESULTS: Of the 544 patients, 164 (30.1%) had prior GDM. Prior GDM significantly increased the likelihood of composite outcome compared to no prior GDM (74.4% vs. 57.4%; P < 0.001). After adjusting for confounders, prior GDM remained significantly associated with the composite outcome (aOR 2.03, 95% confidence interval [CI] 1.31-3.15). Stratifying by prior GDM treatment modality, a significant association was found for prior pharmacotherapy-controlled GDM (aOR 3.29, 95% CI 1.64-6.59), but not for prior diet-controlled GDM (aOR = 1.54, 95% CI 0.92-2.60). CONCLUSION: A history of pharmacotherapy-controlled GDM in a previous pregnancy increases odds of adverse perinatal outcomes in a subsequent GDM pregnancy.

Integrating mifepristone into primary care in Canada's capital: A multi-methods exploration of the Medical Abortion Access Project.

OBJECTIVES: Following the 2017 introduction of mifepristone in Canada and both ensuing regulatory changes and increased demand for medication abortion care, Planned Parenthood Ottawa created the Medical Abortion Access Project (MAAP). This study aimed to document outcomes, identify facilitators and barriers, and distill learnings from an initiative that sought to recruit and support primary care clinicians in providing mifepristone/misoprostol in Canada's capital. STUDY DESIGN: We employed a multi-methods evaluation strategy that included reviewing MAAP-related documents, evaluating the project log, and conducting in-depth interviews with clinicians at 5 sites. In the final analytic phase, we integrated the findings from the different evaluation components. RESULTS: From May 2017 through July 2018, the MAAP helped 14 primary care facilities in Ottawa become medication abortion providers; 9 began providing mifepristone/misoprostol to existing patients and 5 began offering mifepristone/misoprostol to the public. The program recruited 4 new pharmacies to stock the combination package and trained 2 sonography clinics in abortion-related protocols. Program participants identified patient demand as a key driver of medication abortion provision but required information and logistical support from the MAAP to operationalize service delivery. New abortion providers reflected positively on the community of practice that the MAAP created, which enabled them to offer and receive technical and emotional support from colleagues across the city. CONCLUSIONS: A number of primary care clinicians in Ottawa were able to successfully integrate medication abortion care into their practices with MAAP support. Future research should explore whether this type of community-based intervention can be replicated in other settings. IMPLICATIONS: Evidence-based regulation of mifepristone by health authorities is a critical step to increasing access to medication abortion care. However, deregulation alone was insufficient to integrate medication abortion services into primary care in Ottawa. Community-based programs like the MAAP can help providers make sense of shifting regulations and practice guidelines, overcome logistical barriers, and ultimately increase access to this medically necessary service. Establishing and facilitating communities of practice is especially important for new primary care providers.

"I didn't doubt my choice, but I felt bad": A qualitative exploration of Canadian abortion patients' experiences with protesters.

OBJECTIVES: Although a body of research has focused on violence, disruption, and harassment targeting abortion clinics and clinic staff, little research has explored Canadian abortion patients' experiences with protesters. Through this national qualitative study we aimed to address this gap. METHODS: Between 2012 and 2016, we conducted in-depth interviews with 305 Canadian women who had an abortion in the previous five years. Thirty participants reported encountering protesters when seeking abortion care. We focused on this sub-set of interviews and analyzed these data for content and themes using inductive and deductive techniques. RESULTS: Across the country, participants reported encountering protesters holding signs, chanting slogans, and shouting insults. These interactions were concentrated at clinics in New Brunswick, Newfoundland and Labrador, and Ontario. Although no participants reported that these encounters made them reconsider their decision, they did report that seeing and interacting with protesters was at times unsettling, stigmatizing, and frustrating. Participants who struggled with the decision to have an abortion and those who made the decision in the context of health issues or violence found these encounters especially upsetting. Participants discussed how their interactions with protesters and the additional security measures put in place by clinics contrasted with their experiences accessing other kinds of health care and they wished that the protesters had not been there. CONCLUSIONS: For some Canadian abortion patients, encountering protesters is upsetting and stigmatizing. Exploring ways to minimize interactions between protesters and those seeking abortion care, such as enacting and enforcing safe access zone legislation, appears warranted. IMPLICATIONS: Although several Canadian provinces have enacted safe access zone laws, these do not currently exist across all jurisdictions. In addition to protecting clinics and clinic staff, implementation of these buffer zones have the potential to improve some patients' experiences obtaining a medically necessary and essential service.