Do women with a previous unintended birth subsequently experience missed opportunities for postpartum family planning counseling? A multilevel mixed effects analysis.

Client-provider communication about family planning (FP) remains an important strategy for preventing unintended pregnancy. Yet, the literature lacks empirical studies examining whether and how women's intendedness of a recent pregnancy may impact subsequent receipt of FP counseling. We investigated whether the intendedness of a recent pregnancy is associated with subsequent missed opportunities (MOs) for FP counseling, taking into account compositional and contextual factors. We performed a secondary analysis using pooled data from the 2016, 2017 and 2018 Performance Monitoring and Accountability 2020 cross-sectional surveys conducted in Nigeria, adjusting for complex design effects. Weighted multilevel logistic regression modeling was used to examine the relationships between pregnancy intention and MOs, overall and at the health facility, using two-level random intercept models. In the analytic sample of women within 24 months postpartum (N = 6479), nearly 60% experienced MOs for FP counseling overall and even 45% of those who visited a health facility visit in the past 12 months (N = 4194) experienced MOs. In the multivariable models adjusted for individual-/household- and community-level factors, women whose recent birth was either mistimed or unwanted were just as likely to have MOs for FP counseling as their counterparts whose pregnancy was intended (p > 0.05). Factors independently associated with a MOs include individual/household level factors such as level of education, exposure to FP media, household wealth index and contextual-level variables (geographic region). While evidence that pregnancy intendedness is associated with MOs for FP counseling remains inconclusive, efforts to mitigate these MOs requires prioritizing women's prior pregnancy intentions as well as equipping healthcare providers with the capacity need to provide high-quality client-centered FP counseling, particularly for women whose recent birth was unintended.

Is it an abortion: Classification of pregnancy-ending interventions after 24 weeks in the presence of lethal fetal anomalies.

OBJECTIVES: To determine how obstetrician-gynecologists categorize pregnancy-ending interventions in the setting of lethal fetal anomalies. STUDY DESIGN: We conducted a sequential explanatory mixed-methods study of U.S. obstetrician-gynecologists from May to July 2021. We distributed a cross-sectional online survey via email and social media and completed qualitative telephone interviews with a nested group of participants. We assessed institutional classification as induced abortion versus indicated delivery for six scenarios of ending a pregnancy with lethal anomalies after 24 weeks, comparing classification using McNemar chi-square tests with Benjamini-Hochberg correction for multiple comparisons with a false discovery rate of 0.05. We performed the thematic analysis of qualitative data and then performed a mixed-methods analysis. RESULTS: We included 205 respondents; most were female (84.4%), had provided abortion care (80.2%), and were general OB/GYNs (59.3%), with broad representation across pre-Dobbs state and institutional abortion policies. Twenty-one qualitative participants had similar characteristics to the whole sample. All scenarios were classified as induced abortion by the majority of respondents, ranging from 53.2% for 32-week induction for anencephaly, to 82.9% for feticidal injection with 24-week induction for anencephaly. Mixed-methods analysis revealed the relevance of gestational age (later interventions less likely to be considered induced abortion) and procedure method and setting (dilation and evacuation, feticidal injection, and freestanding facility all increasing classification as induced abortion). CONCLUSIONS: There is wide variation in the classification of pregnancy-ending interventions for lethal fetal anomalies, even among trained obstetrician-gynecologists. Method, timing, and location of ending a nonviable pregnancy influence classification, though the perinatal outcome is unchanged. IMPLICATIONS: The classification of pregnancy-ending interventions for lethal fetal anomalies after 24 weeks as indicated delivery versus induced abortion is reflective of sociopolitical regulatory factors as opposed to medical science. The regulatory requirement for classification negatively impacts access to care, especially in environments where induced abortion is legally restricted.

Classification of periviable pregnancy-ending interventions for maternal life endangerment as induced abortion.

OBJECTIVES: To explore how US obstetrician-gynecologists (OB/GYNs) classify periviable pregnancy-ending interventions for maternal life endangerment. STUDY DESIGN: From May to July 2021, we performed an explanatory sequential mixed methods study of US OB/GYNs, recruited through social media and professional listservs. We administered a cross-sectional survey requesting institutional classification of labor induction or surgical evacuation of a 22-week pregnancy affected by intrauterine infection, using chi-square tests and logistic regression to compare determinations by physician and institutional factors. We then conducted semistructured interviews in a diverse nested sample to explore decision-making, merging quantitative and qualitative data in a mixed methods analysis. RESULTS: We received 209 completed survey responses, with 101 (48.3%) current abortion providers and 48 (20.1%) never-providers, and completed 21 qualitative interviews. Fewer than half of respondents reported that pregnancy-ending intervention for 22-week intrauterine infection would be classified as induced abortion at their institution (induction: 21.1%, dilation & evacuation: 42.6%, p < 0.001). In addition to procedure method, decision-making factors for classification as abortion included personal experience with abortion (with more experienced participants more likely to identify care as abortion) and state and institutional abortion regulations ("I have to call it a medical [induction]… I'm not allowed to use the word abortion"). CONCLUSIONS: Most OB/GYNs do not classify periviable pregnancy-ending interventions for life-threatening maternal complications as induced abortion, especially when physicians and institutions have less abortion expertise. Differential classification of pregnancy-ending care may lead to undercounting of later abortion procedures, masking the impact of abortion restrictions. IMPLICATIONS: Under unclear legal definitions, legislative interference, and administrative overreach, subjectivity in classification creates inconsistency in care for pregnancy complications. Failure to classify life-saving care as abortion contributes to stigma and facilitates restrictions, with increased danger and less autonomy for pregnant people.

Access to abortion training.

The changing political landscape has had a significant impact on abortion training in the United States. Access to training in medical and surgical abortion has been improving over the past several decades, though significant barriers exist in training providers adequately. We sought to evaluate access to abortion training to providers, including obstetrician-gynecologists, family practice physicians, and advanced practice providers. Training in contraception, miscarriage management, medication abortion and surgical abortion procedures is a requirement for Obstetrics and Gynecology residents. Limited information exists about the details of residency training, though larger percentages of graduating residents are reporting access to comprehensive family planning training. Initiatives by groups such as Medical Students for Choice and the Kenneth J. Ryan Program have greatly improved access to abortion training by increasing opportunities for resident involvement. Abortion training opportunities exist for Family Medicine residents and advanced practice clinicians, though this training is not mandated and as such, often not standardized. In light of increasingly restrictive legislation and decreasing numbers of abortion providers, concerns exist about the sustainability of abortion training access. Other noteworthy barriers to provider training include hospital policy, lack of expert faculty, and state laws. Ensuring integrated evidence-based and standardized abortion training is important in maintaining access to a full range of family planning services.

Special report: implementing immediate postpartum LARC in Florida.

Women are often highly motivated to obtain contraception during the immediate postpartum period. However, not all women receive contraception, particularly long-acting reversible contraceptive methods, during this time. One barrier to immediate postpartum contraception is the cost of placing long-acting reversible contraceptives, because such devices have a large upfront cost and historically could not be charged separately from the global delivery fee. In 2017, Florida Medicaid unbundled the fee for the long-acting reversible contraceptive device and insertion from the Diagnosis Related Group and encouraged Medicaid Managed Care plans to do the same. The Florida Perinatal Quality Collaborative, in recognition of guidance put forth by other states, designed the Access LARC initiative to have 2 phases: the preimplementation phase and the implementation phase. After completing all steps in the preimplementation phase, 1 pilot hospital placed 195 long-acting reversible contraceptives during the first 5 months of the initiative. During this trial period, setbacks in the reimbursement process occurred for both the hospital and payer groups. The Agency for Health Care Administration was instrumental in providing assistance to overcome these setbacks. Although there were obstacles and setbacks along the way, this initiative was finally a success for our providers and patients. We encourage other hospitals and states to implement their own postpartum long-acting reversible contraceptive initiative with the use of the guidelines set forth by Florida's Access LARC initiative.

Obstetrics and Gynecology and Family Medicine Residents' Training and Knowledge on Emergency Contraception.

Background: Emergency contraception (EC) has the potential to play a vital role in preventing unintended pregnancies after unprotected sexual intercourse or contraceptive failure. Residency training can influence practice behaviors, however, the extent to which EC-related information is taught in training programs remains unknown. This study examined where residents obtain information about EC and whether knowledge differs by resident program characteristics. Materials and Methods: Program coordinators of Obstetrics and Gynecology (OB/GYN) and Family Medicine residency programs (n = 689) were emailed and requested to forward the survey link to residents. The survey included measures of EC education (hours, sources, including lectures, grand rounds), and EC-related knowledge. EC knowledge items assessed the three methods of EC (copper intrauterine device, ulipristal acetate, and oral levonorgestrel), effectiveness, mechanism of action, contraindications, and side effects. t-Tests and analysis of variances were used to compare mean knowledge scores (maximum = 20; higher scores indicating higher knowledge). Results: Among participants (n = 676), 61% were Family Medicine residents, 66% were white, and 72% were female. Overall, 34% received <1 hour of EC education, with OB/GYN residents receiving significantly more hours than Family Medicine residents. OB/GYN residents (mean = 14.40, standard deviation [SD] = 2.69) had a significantly higher mean knowledge score than Family Medicine residents (12.12, SD = 2.63; p < 0.000). Mean knowledge score differences were found by region of residency program, with residents in the Northeast reporting higher knowledge. Conclusions: Overall, residents received very little EC education, with OB/GYN residents receiving more training and having higher knowledge than their Family Medicine counterparts. Additional training is needed to ensure that residents are knowledgeable about this effective method to decrease unintended pregnancies.

Self-Administered Lidocaine Gel for Intrauterine Device Insertion in Nulliparous Women: A Randomized Controlled Trial.

OBJECTIVE: To evaluate self-administration of vaginal lidocaine gel to decrease pain with intrauterine device (IUD) insertion in nulliparous women. METHODS: In this randomized, double-blind, placebo-controlled trial, women self-administered 2% lidocaine or placebo vaginal gel 5 minutes before IUD insertion. The primary outcome was change in pain from baseline to IUD insertion on a 100-mm visual analog scale. We also assessed pain after speculum insertion, tenaculum placement, uterine sounding, and 5 minutes after IUD insertion. Secondary outcomes included patient acceptability, ease of IUD insertion, and need for pain medication for up to 7 days. RESULTS: From July 2012 to May 2013, 59 women were randomized; 30 received lidocaine gel and 29 placebo. Baseline demographics, including age, race, and body mass index, were similar. There was no difference in median change in pain during IUD insertion in women receiving lidocaine (61 mm [interquartile range 53-71]) compared with placebo (69 mm [interquartile range 63-80], P=.06). Women receiving lidocaine experienced less pain with tenaculum placement (32 mm [interquartile range 18-54]) compared with placebo (56 mm [interquartile range 26-75], P=.02). Most (76%) women were satisfied with their IUD insertion experience and 86% would probably or definitely recommend an IUD to a friend. Thirty-four percent of women required pain medication for at least 3 days after IUD insertion. CONCLUSION: For nulliparous women, self-administered vaginal lidocaine gel does not reduce pain with IUD insertion, but does decrease pain with tenaculum placement. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, http://clinicaltrials.gov, NCT01534520.

Routine counseling about intrauterine contraception for women seeking emergency contraception.

OBJECTIVE: To compare contraceptive knowledge and use among women seeking emergency contraception (EC) before and after an inner-city clinic began providing structured counseling and offering same-day intrauterine device (IUD) or implant placement to all women seeking EC. STUDY DESIGN: For 8 months before and 21 months after this change in clinic policy, women aged 15-45 who wanted to avoid pregnancy for at least 6 months were asked to complete surveys immediately, 3 and 12 months after their clinic visit. In addition, we abstracted electronic medical record (EMR) data on all women who sought EC (n=328) during this period. We used chi-squared tests to assess pre/post differences in survey and EMR data. RESULTS: Surveys were completed by 186 women. After the clinic began offering structured counseling, more women had accurate knowledge of the effectiveness of IUDs, immediately and 3 months after their clinic visit. In addition, more women initiated IUD or implant use (survey: 40% vs. 17% preintervention, p=0.04; EMR: 22% vs. 10% preintervention, p=0.01), and fewer had no contraceptive use (survey: 3% vs. 17% preintervention, p<0.01; EMR: 32% vs. 68%, p<0.01) in the 3 months after seeking EC. EMR data indicate that when same-day placement was offered, 11.0% of women received a same-day IUD. Of those who received a same-day IUD, 88% (23/26) reported IUD use at 3-months and 80% (12/15) at 12 months. CONCLUSIONS: Routine provision of structured counseling with the offer of same-day IUD placement increases knowledge and use of IUDs 3 months after women seek EC. IMPLICATIONS: Women seeking EC from family planning clinics should be offered counseling about highly effective reversible contraceptives with the option of same-day contraceptive placement.

Asking for what she needs? Pregnancy testing or EC?

BACKGROUND: When used within 5 days of unprotected sex, emergency contraception (EC) can reduce the risk of pregnancy. Our objective was to explore how often women seeking clinic-based pregnancy testing who do not desire pregnancy might benefit from EC and examine variables associated with patients asking for EC when use is indicated. STUDY DESIGN: Women seeking pregnancy testing or EC from an inner-city Title-X-funded family planning clinic between January 2011 and June 2012 were invited to complete surveys. RESULTS: Twenty-seven percent (n=79) of respondents were seeking EC, and 73% (n=215) were seeking pregnancy testing. Of those seeking pregnancy testing, 39% might have benefited from same-day use of EC pills. Women who had never used EC and who had more than one episode of unprotected sex within the past month were less likely to request EC when use was indicated, while single women were more likely to request EC. CONCLUSIONS: Counseling regarding EC options is particularly important for women seeking same-day pregnancy testing who do not desire pregnancy.

Urethral injury with transobturator midurethral sling.

Transobturator midurethral slings were introduced to avoid retropubic complications such as bladder, urethra, bowel, and major vessel injuries. However, complications are not completely eliminated. We present a urethral injury presenting with urge predominant mixed incontinence. The sling was removed transvaginally. Urethral injuries are now less common than they originally were owing to advances in operative technique and product innovation. However, it is incumbent on physicians to evaluate product characteristics that may affect outcomes in their patients. We further reiterate that thorough cystoscopy with urethroscopy is an essential step when performing transobturator midurethral slings.

The combined oral contraceptive pill containing drospirenone and ethinyl estradiol plus levomefolate calcium.

INTRODUCTION: Neural tube defects are the second most common congenital anomaly in the United States, although their incidence may be decreased by periconception folic acid supplementation. A new oral contraceptive containing drospirenone and ethinyl estradiol plus levomefolate calcium was formulated to decrease the risk of neural tube defects in pregnancies conceived while taking or shortly after discontinuing this pill. AREAS COVERED: Because of its novelty, very few studies have been performed to evaluate the efficacy, side effects and safety related to contraception, premenstrual dysphoric disorder and acne; therefore, literature evaluating similar contraceptives without levomefolate is reviewed. Additionally, we review studies evaluating the addition of levomefolate calcium to oral contraceptives containing 3 mg drospirenone and either 20 or 30 µg ethinyl estradiol. To date, no study has been performed to evaluate the effect this new oral contraceptive has on reducing the incidence of neural tube defects. EXPERT OPINION: This new pill has similar contraceptive efficacy, side effect, safety and benefits profile to other drospirenone-containing contraceptives. While also approved to prevent neural tube defects, no studies validate this claim and physician time is better spent counseling women, regardless of contraceptive choice, on the importance of folic acid supplementation during the child-bearing years.