Contraceptive Method Use Among a Population-Based Cohort During the South Carolina Choose Well Initiative.

Importance: Evaluating the impact of statewide contraceptive access initiatives is necessary for informing health policy and practice. Objective: To examine changes in contraceptive method use among a cohort of women of reproductive age in South Carolina during the Choose Well contraceptive access initiative. Design, Setting, and Participants: In this cohort study, baseline data from the initial Statewide Survey of Women administered from October 1, 2017, to April 30, 2018, to a probability-based sample of women of reproductive age in South Carolina and a peer state (Alabama) were linked with 3 follow-up surveys given in 2019, 2020, and 2021. Responses about contraception use from the initial survey were compared with responses across follow-up surveys using the regression-based differences-in-differences method. Data analysis was performed from October 2023 to February 2024. Exposure: The South Carolina Choose Well contraceptive access initiative seeks to fill contraceptive access gaps and increase provision of a full range of contraceptive methods through engagement with a wide range of health care organizations across the state. Main Outcomes and Measures: Changes in contraceptive method use, including long-acting reversible contraception (LARC), intrauterine devices (IUDs), implants, short-acting hormonal injection, and barrier or other methods between the baseline survey (2017-2018) and 3 subsequent surveys (2019-2021). Results: A total of 1344 female participants (mean [SD] age, 34 [7] years) completed the first survey (667 in Alabama and 677 in South Carolina). Use of LARC significantly increased in South Carolina (119 [17.6%] to 138 [21.1%]) compared with Alabama (120 [18.0%] to 116 [18.1%]; P = .004). Use of IUDs increased in South Carolina (95 [14.0%] to 114 [17.4%]) compared with Alabama (92 [13.8%] to 102 [15.9%]; P = .003). These associations persisted in the adjusted analysis, with a significant increase in the odds of LARC (adjusted odds ratio, 1.24; 95% CI, 1.06-1.44) and IUD (adjusted odds ratio, 1.19; 95% CI, 1.06-1.32) use at follow-up in South Carolina compared with Alabama. Conclusions and Relevance: In this cohort study of 1344 participants, increases in the use of IUDs in South Carolina were noted after the implementation of the South Carolina Choose Well initiative that were not observed in a peer state with no intervention. Our findings may provide support in favor of statewide contraceptive access initiatives and their role in promoting access to reproductive health services.

Contraceptive counseling, method satisfaction, and planned method continuation among women in the U.S. southeast.

OBJECTIVES: We used the validated Person-Centered Contraceptive Counseling (PCCC) scale to examine experiences with counseling and associations between counseling quality, method satisfaction, and planned method continuation at the population level in two southeastern states. STUDY DESIGN: We used data from the Statewide Survey of Women, a probability-based sample of reproductive-aged women in Alabama and South Carolina in 2017/18. We included women using a contraceptive method and reporting a contraceptive visit in the past year (n = 1265). Respondents rated their most recent provider experience across four PCCC items. Regression analyses examined relationships between counseling quality and outcomes of interest, and path analysis examined the extent to which method satisfaction mediated the effects of counseling quality on planned continuation. RESULTS: Over half of participants (54%) reported optimal contraceptive counseling. Optimal counseling was associated with method satisfaction (aPR = 1.16; 95% confidence interval (CI) = 1.04-1.29) in adjusted models. Optimal counseling was marginally associated with planned discontinuation in the bivariate analysis but was attenuated in the adjusted model (aPR = 1.07; 95% CI = 0.98-1.18). In the path analysis, counseling quality influenced method satisfaction (0.143 (0.045), p = 0.001) which influenced planned continuation, controlling for PCCC (0.74 (0.07), p < 0.001). The total indirect effect of counseling quality on planned continuation was significant (0.106 (0.03), p = 0.001), and a residual direct effect from counseling quality to planned continuation was noted (0.106 (0.03), p = 0.001). CONCLUSIONS: Counseling quality is independently associated with method satisfaction at the population level. The effect of counseling on planned continuation is partially mediated by method satisfaction. IMPLICATIONS: Interventions to support person-centered contraceptive counseling promise to improve quality of care, patient experience with care, and reproductive outcomes.

Effects of Aircraft Noise on Sleep: Federal Aviation Administration National Sleep Study Protocol.

Aircraft noise can disrupt sleep and impair recuperation. The last U.S. investigation into the effects of aircraft noise on sleep dates back more than 20 years. Since then, traffic patterns and the noise levels produced by single aircraft have changed substantially. It is therefore important to acquire current data on sleep disturbance relative to varying degrees of aircraft noise exposure in the U.S. that can be used to check and potentially update the existing noise policy. This manuscript describes the design, procedures, and analytical approaches of the FAA's National Sleep Study. Seventy-seven U.S. airports with relevant nighttime air traffic from 39 states are included in the sampling frame. Based on simulation-based power calculations, the field study aims to recruit 400 participants from four noise strata and record an electrocardiogram (ECG), body movement, and sound pressure levels in the bedroom for five consecutive nights. The primary outcome of the study is an exposure-response function between the instantaneous, maximum A-weighted sound pressure levels (dBA) of individual aircraft measured in the bedroom and awakening probability inferred from changes in heart rate and body movement. Self-reported sleep disturbance due to aircraft noise is the secondary outcome that will be associated with long-term average noise exposure metrics such as the Day-Night Average Sound Level (DNL) and the Nighttime Equivalent Sound Level (Lnight). The effect of aircraft noise on several other physiological and self-report outcomes will also be investigated. This study will provide key insights into the effects of aircraft noise on objectively and subjectively assessed sleep disturbance.

Impact of the Choose Well Initiative on Contraceptive Access at Federally Qualified Health Centers in South Carolina: A Midline Evaluation.

Choose Well (CW) is a statewide contraceptive access initiative to reduce unintended pregnancy among patients utilizing federally funded family planning services. We examined CW's impact on contraceptive access at South Carolina federally qualified health centers from 2016 to 2019, which reported significantly higher increases in providing the full range of contraceptive methods and training onsite. CW prioritized ensuring change sustainability through obtaining funding and institutionalizing changes. (Am J Public Health. 2023;113(11):1167-1172. https://doi.org/10.2105/AJPH.2023.307384).

Association of Health Insurance with Contraceptive Use and Interpersonal Quality of Contraceptive Care in the Southeast United States.

OBJECTIVES: Health insurance remains an important dimension of contraceptive access. This study investigated the role of insurance in contraceptive use, access, and quality in South Carolina and Alabama. METHODS: The study used a cross-sectional statewide representative survey that assessed reproductive health experiences and contraceptive use among reproductive-age women in South Carolina and Alabama. The primary outcomes were current contraceptive method use, barriers to access (inability to afford wanted method, delay/trouble obtaining wanted method), receipt of any contraceptive care in the past 12 months, and perceived quality of care. The independent variable was insurance type. Generalized linear models were applied to estimate prevalence ratios for each outcome's association with insurance type while adjusting for potentially confounding variables. RESULTS: Nearly 1 in 5 women (17.6%) was uninsured, and 1 in 4 women (25.3%) reported not using a contraceptive method at the time of the survey. Compared with women with private insurance, women with no insurance had a lower likelihood of current method use (adjusted prevalence ratio 0.75; 95% confidence interval 0.60-0.92) and receipt of contraceptive care in the past 12 months (adjusted prevalence ratio 0.61; 95% confidence interval 0.45-0.82). These women also were more likely to experience cost barriers to access care. The insurance type was not significantly associated with the interpersonal quality of contraceptive care. CONCLUSIONS: Findings highlight the need for expanding Medicaid in states that did not do so under the Patient Protection and Affordable Care Act, interventions to increase the number of providers who accept Medicaid patients, and protections to Title X funding as key elements for enhancing contraceptive access and population health outcomes.

Associations of bedroom PM2.5, CO2, temperature, humidity, and noise with sleep: An observational actigraphy study.

OBJECTIVE: Climate change and urbanization increasingly cause extreme conditions hazardous to health. The bedroom environment plays a key role for high-quality sleep. Studies objectively assessing multiple descriptors of the bedroom environment as well as sleep are scarce. METHODS: Particulate matter with a particle size <2.5 µm (PM2.5), temperature, humidity, carbon dioxide (CO2), barometric pressure, and noise levels were continuously measured for 14 consecutive days in the bedroom of 62 participants (62.9% female, mean ± SD age: 47.7 ± 13.2 years) who wore a wrist actigraph and completed daily morning surveys and sleep logs. RESULTS: In a hierarchical mixed effect model that included all environmental variables and adjusted for elapsed sleep time and multiple demographic and behavioral variables, sleep efficiency calculated for consecutive 1-hour periods decreased in a dose-dependent manner with increasing levels of PM2.5, temperature, CO2, and noise. Sleep efficiency in the highest exposure quintiles was 3.2% (PM2.5, p < .05), 3.4% (temperature, p < .05), 4.0% (CO2, p < .01), and 4.7% (noise, p < .0001) lower compared to the lowest exposure quintiles (all p-values adjusted for multiple testing). Barometric pressure and humidity were not associated with sleep efficiency. Bedroom humidity was associated with subjectively assessed sleepiness and poor sleep quality (both p < .05), but otherwise environmental variables were not statistically significantly associated with actigraphically assessed total sleep time and wake after sleep onset or with subjectively assessed sleep onset latency, sleep quality, and sleepiness. Assessments of bedroom comfort suggest subjective habituation irrespective of exposure levels. CONCLUSIONS: These findings add to a growing body of evidence highlighting the importance of the bedroom environment-beyond the mattress-for high-quality sleep.

Increases in IUD Provision at Alabama Department of Public Health Clinics From 2016 to 2019.

The Alabama Department of Public Health (ADPH) began allocating Title X funding to intrauterine device (IUD) provision at family planning clinics in 2019, instated more training opportunities, and expanded nurse practitioner scope of practice to include IUD placements. We assessed IUD provision and protocols at ADPH Title X clinics in 2016 and 2019 before and after ADPH policy changes. Generalized binomial regression models assessed differences between years. The proportion of ADPH clinics reporting offering any IUD on-site increased by 61.6 percentage points ( P < .001), stockpiling IUDs on-site increased by 85.9 percentage points ( P < .001), IUD placement/removal training increased by 71.4 percentage points ( P < .001), and same-visit IUD placement trainings increased by 64.1 percentage points ( P < .001). Advanced practice nurses were significantly more likely to place IUDs in 2019 compared with 2016 ( P < .001). These findings highlight the positive impact of policy changes related to Title X funding allocation and scope of practice on provision of a full range of contraceptive methods. These changes in policies and practices at the state and local levels within ADPH have expanded the availability of the full range of contraceptive options across the state of Alabama. This expanded access to contraceptive options is especially important given the rapid changes in reproductive health policies occurring in Alabama and across the United States.

Contraceptive care service provision via telehealth early in the COVID-19 pandemic at rural and urban federally qualified health centers in 2 southeastern states.

PURPOSE: To investigate telehealth use for contraceptive service provision among rural and urban federally qualified health centers (FQHCs) in Alabama (AL) and South Carolina (SC) during the initial months of the COVID-19 pandemic. METHODS: This is a mixed-methods study using data from the FQHC Contraceptive Care Survey and key informant interviews with FQHC staff in AL and SC conducted in 2020. Differences between rural and urban clinics in telehealth use for contraceptive service provision were assessed with a chi-square test of independence. Interviews were audio recorded, transcribed, and coded to identify facilitators and barriers to telehealth. FINDINGS: Telehealth for contraceptive care increased during the early months of the pandemic relative to prepandemic. Fewer rural clinics than urban clinics provided telehealth for contraceptive counseling (16.3% vs 50.6%) (P = .0002), emergency contraception (0.0% vs 16.1%) (P = .004), and sexually transmitted infection care (16.3% vs 34.6%) (P = .031). Key facilitators of telehealth were reimbursement policy, electronic infrastructure and technology, and funding for technology. Barriers included challenges with funding for telehealth, limited electronic infrastructure, and reduced staffing capacity. CONCLUSIONS: Differences in telehealth service provision for contraceptive care between rural and urban FQHCs highlight the need for supportive strategies to increase access to care for low-income rural populations, particularly in AL and SC. It is essential for public and private entities to support the implementation and continuation of telehealth among rural clinics, particularly, investing in widespread and clinic-level electronic infrastructure and technology for telehealth, such as broadband and electronic health record systems compatible with telehealth technology.

Ranges of pregnancy preferences and contraceptive use: Results from a population-based survey in the southeast United States.

CONTEXT: Understanding how pregnancy preferences shape contraceptive use is essential for guiding contraceptive interventions and policies that center individuals' preferences and desires. Lack of rigorous measurement of pregnancy preferences, particularly on the population level, has been a methodologic challenge. METHODS: We investigated associations between prospective pregnancy preferences, measured with a valid instrument, the Desire to Avoid Pregnancy (DAP) scale, and contraceptive use in a representative sample of 2601 pregnancy-capable self-identified women, aged 18-44 years, in Alabama and South Carolina (2017-2018). We used multivariable regression with weighting to investigate how probability of modern contraceptive use, and use of different contraceptive method types, changed with increasing preference to avoid pregnancy. RESULTS: Desire to Avoid Pregnancy scale scores (range:0-4, 4 = greater preference to avoid pregnancy, median = 2.29, IQR: 1.57-3.14; α:0.95) were strongly associated with contraceptive use among sexually active respondents (aPR = 1.15 [1.10, 1.20]; predicted 45% using contraception among DAP = 0, 62% among DAP = 2, 86% among DAP = 4). Method types used did not differ by DAP score. The most common reasons for nonuse were concern over side effects and not wanting to use a method (32% each) among respondents with mid-range and high DAP scores. Among those with mid-range DAP scores, 20% reported nonuse due to not minding if pregnancy were to occur (vs. 0% among those with high DAP scores). CONCLUSIONS: Pregnancy preferences strongly influence likelihood of contraceptive use. Providion of appropriate contraceptive care to those not explicitly desiring pregnancy must differentiate between ranges of feelings about pregnancy, perceived drawbacks to contraceptive use, and legitimate psychological and interpersonal benefits of nonuse to promote autonomy in contraceptive decision-making.

Environmental Noise and Effects on Sleep: An Update to the WHO Systematic Review and Meta-Analysis.

BACKGROUND: Nighttime noise carries a significant disease burden. The World Health Organization (WHO) recently published guidelines for the regulation of environmental noise based on a review of evidence published up to the year 2015 on the effects of environmental noise on sleep. OBJECTIVES: This systematic review and meta-analysis will update the WHO evidence review on the effects of environmental noise on sleep disturbance to include more recent studies. METHODS: Investigations of self-reported sleep among residents exposed to environmental traffic noise at home were identified using Scopus, PubMed, Embase, and PsycINFO. Awakenings, falling asleep, and sleep disturbance were the three outcomes included. Extracted data were used to derive exposure-response relationships for the probability of being highly sleep disturbed by nighttime noise [average outdoor A-weighted noise level (Lnight) 2300-0700 hours] for aircraft, road, and rail traffic noise, individually. The overall quality of evidence was assessed using Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) criteria. RESULTS: Eleven studies (n=109,070 responses) were included in addition to 25 studies (n=64,090 responses) from the original WHO analysis. When sleep disturbance questions specifically mentioned noise as the source of disturbance, there was moderate quality of evidence for the probability of being highly sleep disturbed per 10-dB increase in Lnight for aircraft [odds ratio (OR)=2.18; 95% confidence interval (CI): 2.01, 2.36], road (OR=2.52; 95% CI: 2.28, 2.79), and railway (OR=2.97; 95% CI: 2.57, 3.43) noise. When noise was not mentioned, there was low to very low quality of evidence for being sleep disturbed per 10-dB increase in Lnight for aircraft (OR=1.52; 95% CI: 1.20, 1.93), road (OR=1.14; 95% CI: 1.08, 1.21), and railway (OR=1.17; 95% CI: 0.91, 1.49) noise. Compared with the original WHO review, the exposure-response relationships closely agreed at low (40 dB Lnight) levels for all traffic types but indicated greater disturbance by aircraft traffic at high noise levels. Sleep disturbance was not significantly different between European and non-European studies. DISCUSSION: Available evidence suggests that transportation noise is negatively associated with self-reported sleep. Sleep disturbance in this updated meta-analysis was comparable to the original WHO review at low nighttime noise levels. These low levels correspond to the recent WHO noise limit recommendations for nighttime noise, and so these findings do not suggest these WHO recommendations need revisiting. Deviations from the WHO review in this updated analysis suggest that populations exposed to high levels of aircraft noise may be at greater risk of sleep disturbance than determined previously. https://doi.org/10.1289/EHP10197.

Multilevel Influences on Providers' Delivery of Contraceptive Services: A Qualitative Thematic Analysis.

Introduction: Access to a full range of contraceptive services is essential for quality health care. Contraceptive provision practices of primary care providers play an important role in patients' decision-making about their reproductive health care. Understanding the multilevel factors influencing contraceptive care delivery in primary care settings is critical for advancing quality care. This study offers an in-depth examination of influences on providers' delivery of contraceptive services across multiple primary care specialties and practice settings to identify issues and strategies to improve care. Materials and Methods: Twenty-four in-depth face-to-face interviews were conducted in 2017 with primary care providers, including family physicians, gynecologists, pediatricians, and nurse practitioners from academic settings, private practices, and health centers. Interviews were transcribed and analyzed thematically. Results: Providers described a complex set of influences on their provision of contraception across multiple ecological contexts. Seven major themes emerged from the qualitative analysis, including six types of influence on provision of contraception: organizational, individual provider-related, structural and policy, individual patient-related, community, and the lack of influences or barriers. Providers also discussed the sources they access for information about evidence-based contraception counseling. Conclusions: A diverse set of providers described a complex system in which multiple concentric ecological contexts both positively and negatively influence the ways in which they provide contraceptive services to their patients. To close the gaps in contraceptive service delivery, it is important to recognize that both barriers and facilitators to patient-centered contraceptive counseling exist simultaneously across multiple ecological contexts.

Dynamic ensemble prediction of cognitive performance in spaceflight.

During spaceflight, astronauts face a unique set of stressors, including microgravity, isolation, and confinement, as well as environmental and operational hazards. These factors can negatively impact sleep, alertness, and neurobehavioral performance, all of which are critical to mission success. In this paper, we predict neurobehavioral performance over the course of a 6-month mission aboard the International Space Station (ISS), using ISS environmental data as well as self-reported and cognitive data collected longitudinally from 24 astronauts. Neurobehavioral performance was repeatedly assessed via a 3-min Psychomotor Vigilance Test (PVT-B) that is highly sensitive to the effects of sleep deprivation. To relate PVT-B performance to time-varying and discordantly-measured environmental, operational, and psychological covariates, we propose an ensemble prediction model comprising of linear mixed effects, random forest, and functional concurrent models. An extensive cross-validation procedure reveals that this ensemble outperforms any one of its components alone. We also identify the most important predictors of PVT-B performance, which include an individual's previous PVT-B performance, reported fatigue and stress, and temperature and radiation dose. This method is broadly applicable to settings where the main goal is accurate, individualized prediction of human behavior involving a mixture of person-level traits and irregularly measured time series.

Telehealth for Contraceptive Care During the Initial Months of the COVID-19 Pandemic at Local Health Departments in 2 US States: A Mixed-Methods Approach.

OBJECTIVES: This study examined implementation of telehealth for contraceptive care among health departments (HDs) in 2 Southern US states with centralized/largely centralized governance structures during the early phase of the COVID-19 pandemic. Sustaining access to contraceptive care for underserved communities during public health emergencies is critical. Identifying facilitators and barriers to adaptive service provision helps inform state-level decision making and has implications for public health policy and practice, particularly in states with centralized HD governance. DESIGN: Mixed-methods study including a survey of HD clinic administrators and key informant interviews with clinic- and system-level staff in 2 states conducted in 2020. SETTING: Health department clinics in 2 Southern US states. PARTICIPANTS: Clinic administrators (survey) and clinic- and system-level respondents (key informant interviews). Participation in the research was voluntary and de-identified. MAIN OUTCOME MEASURES: (1) Telehealth implementation for contraceptive care assessed by survey and measured by the percentage of clinics reporting telehealth service provision during the pandemic; and (2) facilitators and barriers to telehealth implementation for contraceptive care assessed by key informant interviews. For survey data, bivariate differences between the states in telehealth implementation for contraceptive care were assessed using χ2 and Fisher exact tests. Interview transcripts were coded, with emphasis on interrater reliability and consensus coding, and analyzed for emerging themes. RESULTS: A majority of HD clinics in both states (60% in state 1 and 81% in state 2) reported a decrease in contraceptive care patient volume during March-June 2020 compared with the average volume in 2019. More HD clinics in state 1 than in state 2 implemented telehealth for contraceptive services, including contraceptive counseling, initial and refill hormonal contraception, emergency contraception and sexually transmitted infection care, and reported facilitators of telehealth. Medicaid reimbursement was a predominant facilitator of telehealth, whereas lack of implementation policies and procedures and reduced staffing capacity were predominant barriers. Electronic infrastructure and technology also played a role. CONCLUSIONS: Implementation of telehealth for contraceptive services varied between state HD agencies in the early phase of the pandemic. Medicaid reimbursement policy and directives from HD agency leadership are key to telehealth service provision among HDs in centralized states.

Geographic differences in contraception provision and utilization among federally funded family planning clinics in South Carolina and Alabama.

PURPOSE: Access to the full range of contraceptive options is essential to providing patient-centered reproductive health care. Women living in rural areas often experience more barriers to contraceptive care than women living in urban areas. Therefore, federally funded family planning clinics are important for ensuring women have access to contraceptive care, especially in rural areas. This study examines contraceptive provision, factors supporting contraceptive provision, and contraceptive utilization among federally funded family planning clinics in 2 Southern states. METHODS: All health department and Federally Qualified Health Center clinics in Alabama and South Carolina that offer contraceptive services were surveyed in 2017-2018. Based on these surveys, we examined differences between rural and urban clinics in the following areas: clinic characteristics, services offered, staffing, staff training, policies, patient characteristics, contraceptive provision, and contraceptive utilization. Differences were assessed using Chi-square tests of independence for categorical variables and independent t-tests for continuous variables. FINDINGS: Urban clinics had more staff on average than rural clinics, but rural clinics reported greater ease in recruiting and retaining family planning providers. Patient characteristics did not significantly vary between rural and urban clinics. While no significant differences were observed in the provision of long-acting reversible contraceptives (LARCs) overall, a greater proportion of patients in urban clinics utilized LARCs. CONCLUSIONS: While provision of most contraceptives is similar between rural and urban federally funded family planning clinics, important differences in other factors continue to result in women who receive care in rural clinics being less likely to choose LARC methods.

Traffic noise-induced changes in wake-propensity measured with the Odds-Ratio Product (ORP).

Nocturnal traffic noise can disrupt sleep and impair physical and mental restoration, but classical sleep scoring techniques may not fully capture subtle yet clinically relevant alterations of sleep induced by noise. We used a validated continuous measure of sleep depth and quality based on automatic analysis of physiologic sleep data, termed Wake Propensity (WP), to investigate temporal changes of sleep in response to nocturnal noise events in 3-s epochs. Seventy-two healthy participants (mean age 40.3 years, range 18-71 years, 40 females, 32 males) slept for 11 nights in a laboratory, during which we measured sleep with polysomnography. In 8 nights, participants were exposed to 40, 80 or 120 road, rail and/or aircraft noise events with maximum noise levels of 45-65 dB LAS,max during 8-h sleep opportunities. We analyzed sleep macrostructure and event-related change of WP during noise exposure with linear mixed models. Nocturnal traffic noise led to event-related shifts towards wakefulness and less deep, more unstable sleep (increase in WP relative to pre-noise baseline ranging from +29.5% at 45 dB to +38.3% at 65 dB; type III effect p < 0.0001). Sleep depth decreased dynamically with increasing noise level, peaking when LAS,max was highest. This change in WP was stronger and occurred more quickly for events where the noise onset was more rapid (road and rail) compared to more gradually time-varying noise (aircraft). Sleep depth did not immediately recover to pre-noise WP, leading to decreased sleep stability across the night compared to quiet nights, which was greater with an increasing number of noise events (standardized ß = 0.053, p = 0.003). Further, WP was more sensitive to noise than classical arousals. Results demonstrate the usefulness of WP as a measure of the effects of external stimuli on sleep, and show WP is a more sensitive measure of noise-induced sleep disruption than traditional methods of sleep analysis.

Labor market participation and productivity costs for female caregivers of minor male children with Duchenne and Becker muscular dystrophies.

INTRODUCTION/AIMS: Duchenne and Becker muscular dystrophies (DBMD) are X-linked neuromuscular disorders characterized by progressive muscle weakness, leading to decreased mobility and multisystem complications. We estimate productivity costs attributable to time spent by a parent caring for a male child under the age of 18 y with DBMD, with particular focus on female caregivers of boys with Duchenne muscular dystrophy (DMD) who have already lost ambulation. METHODS: Primary caregivers of males with DBMD in the Muscular Dystrophy Surveillance and Research Tracking Network (MD STARnet) were surveyed during 2011-2012 on family quality of life measures, including labor market outcomes. Of 211 respondents, 96 female caregivers of boys with DBMD were matched on state, year of survey, respondent's age, child's age, and number of minor children with controls constructed from Current Population Survey extracts. Regression analysis was used to estimate labor market outcomes and productivity costs. RESULTS: Caregivers of boys with DBMD worked 296 h less per year on average than caregivers of unaffected children, translating to a $8816 earnings loss in 2020 U.S. dollars. Caregivers of boys with DMD with ≥4 y of ambulation loss had a predicted loss in annualized earnings of $23,995, whereas caregivers of boys with DBMD of the same ages who remained ambulatory had no loss of earnings. DISCUSSION: Female caregivers of non-ambulatory boys with DMD face additional household budget constraints through income loss. Failure to include informal care costs in economic studies could understate the societal cost-effectiveness of strategies for managing DMD that might prolong ambulation.