Visits to Registered Nurses: An Opportunity to Increase Contraceptive Access in California.

BACKGROUND: In 2013, California passed Assembly Bill (A.B.) 2348, approving registered nurses (RNs) to dispense patient self-administered hormonal contraceptives and administer injections of hormonal contraceptives. The Family Planning, Access, Care and Treatment (Family PACT) program, which came into effect in 1997 to expand low-income, uninsured California resident access to contraceptives at no cost, is one program in which qualified RNs can dispense and administer contraceptives. AIMS: The aims of this study were to (a) describe utilization of RN visits within California's Family PACT program and (b) evaluate the impact of RN visits on client birth control acquisition during the first 18 months after implementation of A.B. 2348 (January 1, 2013 to June 30, 2014). METHODS: A descriptive observational design using administrative databases was used. Family PACT claims were retrieved for RN visits and contraception. Paid claims for contraceptive dispensing and/or administration visits by physicians, nurse practitioners, certified nurse midwives, and physician assistants were compared before and after the implementation of A.B. 2348 at practice sites where RN visits were and were not utilized. Contraceptive methods and administration procedures were identified using Healthcare Common Procedure Coding System codes, National Drug Codes, and Common Procedural Terminology codes. Claims data for healthcare facilities were abstracted by site location based on a unique combination of National Provider Identifier (NPI), NPI Owner, and NPI location number. RESULTS: RN visits were found mainly in Northern California and the Central Valley (73%). Sixty-eight percent of RN visits resulted in same-day dispensing and/or administration of hormonal (and/or barrier) methods. Since benefit implementation, RN visits resulted in a 10% increase in access to birth control dispensing and/or administration visits. RN visits were also associated with future birth control acquisition and other healthcare utilization within the subsequent 30 days. DISCUSSION: RN visits, though underutilized across the state, have resulted in increased access to contraception in some communities, an effect that may continue to grow with time and can serve as a model for other states.

Reductions in pregnancy rates in the USA with long-acting reversible contraception: a cluster randomised trial.

BACKGROUND: Unintended pregnancy remains a serious public health challenge in the USA. We assessed the effects of an intervention to increase patients' access to long-acting reversible contraceptives (LARCs) on pregnancy rates. METHODS: We did a cluster randomised trial in 40 reproductive health clinics across the USA in 2011-13. 20 clinics were randomly assigned to receive evidence-based training on providing counselling and insertion of intrauterine devices (IUDs) or progestin implants and 20 to provide standard care. Usual costs for contraception were maintained at all sites. We recruited women aged 18-25 years attending family planning or abortion care visits and not desiring pregnancy in the next 12 months. The primary outcome was selection of an IUD or implant at the clinic visit and secondary outcome was pregnancy within 12 months. We used generalised estimating equations for clustered data to measure the intervention effect on contraceptive selection, and used survival analysis to assess pregnancy rates. FINDINGS: Of 1500 women enrolled, more at intervention than control sites reported receiving counselling on IUDs or implants (565 [71%] of 797 vs 271 [39%] of 693, odds ratio 3·8, 95% CI 2·8-5·2) and more selected LARCs during the clinic visit (224 [28%] vs 117 [17%], 1·9, 1·3-2·8). The pregnancy rate was lower in intervention group than in the control group after family planning visits (7·9 vs 15·4 per 100 person-years), but not after abortion visits (26·5 vs 22·3 per 100 person-years). We found a significant intervention effect on pregnancy rates in women attending family planning visits (hazard ratio 0·54, 95% CI 0·34-0·85). INTERPRETATION: The pregnancy rate can be reduced by provision of counselling on long-term reversible contraception and access to devices during family planning counselling visits. FUNDING: William and Flora Hewlett Foundation.

Public Funding for Contraception, Provider Training, and Use of Highly Effective Contraceptives: A Cluster Randomized Trial.

OBJECTIVES: We determined whether public funding for contraception was associated with long-acting reversible contraceptive (LARC) use when providers received training on these methods. METHODS: We evaluated the impact of a clinic training intervention and public funding on LARC use in a cluster randomized trial at 40 randomly assigned clinics across the United States (2011-2013). Twenty intervention clinics received a 4-hour training. Women aged 18 to 25 were enrolled and followed for 1 year (n = 1500: 802 intervention, 698 control). We estimated the effects of the intervention and funding sources on LARC initiation with Cox proportional hazards models with shared frailty. RESULTS: Women at intervention sites had higher LARC initiation than those at control (22 vs 18 per 100 person-years; adjusted hazard ratio [AHR] = 1.43; 95% confidence interval [CI] = 1.04, 1.98). Participants receiving care at clinics with Medicaid family planning expansion programs had almost twice the initiation rate as those at clinics without (25 vs 13 per 100 person-years; AHR = 2.26; 95% CI = 1.59, 3.19). LARC initiation also increased among participants with public (AHR = 1.56; 95% CI = 1.09, 2.22) but not private health insurance. CONCLUSIONS: Public funding and provider training substantially improve LARC access.

"Sometimes they used to whisper in our ears": health care workers' perceptions of the effects of abortion legalization in Nepal.

BACKGROUND: Unsafe abortion has been a significant cause of maternal morbidity and mortality in Nepal. Since legalization in 2002, more than 1,200 providers have been trained and 487 sites have been certified for the provision of safe abortion services. Little is known about health care workers' views on abortion legalization, such as their perceptions of women seeking abortion and the implications of legalization for abortion-related health care. METHODS: To complement a quantitative study of the health effects of abortion legalization in Nepal, we conducted 35 in-depth interviews with physicians, nurses, counsellors and hospital administrators involved in abortion care and post-abortion complication treatment services at four major government hospitals. Thematic analysis techniques were used to analyze the data. RESULTS: Overall, participants had positive views of abortion legalization - many believed the severity of abortion complications had declined, contributing to lower maternal mortality and morbidity in the country. A number of participants indicated that the proportion of women obtaining abortion services from approved health facilities was increasing; however, others noted an increase in the number of women using unregulated medicines for abortion, contributing to rising complications. Some providers held negative judgments about abortion patients, including their reasons for abortion. Unmarried women were subject to especially strong negative perceptions. A few of the health workers felt that the law change was encouraging unmarried sexual activity and carelessness around pregnancy prevention and abortion, and that repeat abortion was becoming a problem. Many providers believed that although patients were less fearful than before legalization, they remained hesitant to disclose a history of induced abortion for fear of judgment or mistreatment. CONCLUSIONS: Providers were generally positive about the implications of abortion legalization for the country and for women. A focus on family planning and post-abortion counselling may be welcomed by providers concerned about multiple abortions. Some of the negative judgments of women held by providers could be tempered through values-clarification training, so that women are supported and comfortable sharing their abortion history, improving the quality of post-abortion treatment of complications.

Roe 2022: It's Not 1972.

The recent U.S. Supreme Court decision cannot take obstetricians and gynecologists back to 1972, because abortion practice, training, and research have made 50 years of progress. During this past half century, safe and effective medication and surgical abortion have helped millions of patients, thousands of obstetrician-gynecologists have been trained in more than 100 programs, and thousands of clinical, epidemiologic, and sociologic studies have demonstrated the importance of abortion to personal and public health. Obstetrician-gynecologists must support one another in amending or defying laws that subvert the principles of medical practice, training, and evidence.

Family planning and the future.

The adoption of Title X in 1971 provided for public funding for family planning in the United States but funding from this program has not kept pace with demand for contraceptives. In 1997, The California Department of Public Health established the Family Planning, Access, Care, and Treatment (PACT) Program, a public-private partnership to meet the needs of Californians, including about a half-million adolescents, who did not have access to contraceptive services. The program has saved the state billions of dollars in maternity and abortion costs, dramatically reduced teen pregnancy rates, and serves as a good example for other states.

The future of contraception: the future leaders of family planning.

The University of California, San Francisco, initiated a Fellowship in Family Planning in 1991, and since then 23 academic teaching hospitals across the country have adopted the 2 year program model for training obstetrician-gynecologist physicians in a subspecialty focused on contraception and abortion. The program follows a curriculum that includes clinical practice, research, and international work. This review includes information about the Fellowship in Family Planning as well as research opportunities available from academia, independent foundations, and government related sources.

Intrauterine Devices and Sexually Transmitted Infection among Older Adolescents and Young Adults in a Cluster Randomized Trial.

STUDY OBJECTIVE: Provider misconceptions regarding intrauterine device (IUD) safety for adolescents and young women can unnecessarily limit contraceptive options offered; we sought to evaluate rates of Neisseria gonorrhoeae or Chlamydia trachomatis (GC/CT) diagnoses among young women who adopted IUDs. DESIGN: Secondary analysis of a cluster-randomized provider educational trial. SETTING: Forty US-based reproductive health centers. PARTICIPANTS: We followed 1350 participants for 12 months aged 18-25 years who sought contraceptive care. INTERVENTIONS: The parent study assessed the effect of provider training on evidence-based contraceptive counseling. MAIN OUTCOME MEASURES: We assessed incidence of GC/CT diagnoses according to IUD use and sexually transmitted infection risk factors using Cox regression modeling and generalized estimating equations. RESULTS: Two hundred four participants had GC/CT history at baseline; 103 received a new GC/CT diagnosis over the 12-month follow-up period. IUDs were initiated by 194 participants. Incidence of GC/CT diagnosis was 10.0 per 100 person-years during IUD use vs 8.0 otherwise. In adjusted models, IUD use (adjusted hazard ratio [aHR], 1.31; 95% confidence interval [CI], 0.71-2.40), adolescent age (aHR, 1.28; 95% CI, 0.72-2.27), history of GC/CT (aHR, 1.23; 95% CI, 0.75-2.00), and intervention status (aHR, 1.12; 95% CI, 0.74-1.71) were not associated with GC/CT diagnosis; however, new GC/CT diagnosis rates were significantly higher among individuals who reported multiple partners at baseline (aHR, 2.0; 95% CI, 1.34-2.98). CONCLUSION: In this young study population with GC/CT history, this use of IUDs was safe and did not lead to increased GC/CT diagnoses. However, results highlighted the importance of dual sexually transmitted infection and pregnancy protection for participants with multiple partners.

Intrauterine progestins, progesterone antagonists, and receptor modulators: a review of gynecologic applications.

Intrauterine progestins, progesterone receptor modulators, and antagonists have many important current and potential gynecologic applications. This article will describe the evidence for use of intrauterine progestin for common gynecologic conditions beyond its important role in contraception. We will review the evidence for use of intrauterine progestin delivery for menorrhagia, endometriosis management, adenomyosis treatment, uterine fibroids, endometrial hyperplasia, and its concurrent use in women on hormone replacement therapy or tamoxifen.

Maternal Mortality in the United States Compared With Ethiopia, Nepal, Brazil, and the United Kingdom: Contrasts in Reproductive Health Policies.

Maternal mortality is falling in most of the world's countries, but, for 20 years, the United States has seen no reduction. Over this period, a dozen countries in various stages of development, all spending much less than the United States on health, achieved their United Nations' Millennium Development Goal of 2015 (Millennium Development Goal 5: improve maternal health), with substantial reductions in maternal mortality rates. To consider whether interventions successful in reducing global maternal mortality rates could help the United States to lower its rate, the American College of Obstetricians and Gynecologists, at the 2018 International Federation of Gynecology and Obstetrics' Rio de Janeiro World Congress, convened a panel of the presidents and representatives from five national societies with wide maternal mortality rate ranges and health expenditures and whose national societies had focused on reducing maternal mortality for Millennium Development Goal 5. They identified expanded access to reproductive health care, particularly contraception and safe abortion, as key interventions that had proven effective in decreasing maternal mortality rates worldwide.

Cost savings from the provision of specific methods of contraception in a publicly funded program.

OBJECTIVES: We examined the cost-effectiveness of contraceptive methods dispensed in 2003 to 955,000 women in Family PACT (Planning, Access, Care and Treatment), California's publicly funded family planning program. METHODS: We estimated the number of pregnancies averted by each contraceptive method and compared the cost of providing each method with the savings from averted pregnancies. RESULTS: More than half of the 178,000 averted pregnancies were attributable to oral contraceptives, one fifth to injectable methods, and one tenth each to the patch and barrier methods. The implant and intrauterine contraceptives were the most cost-effective, with cost savings of more than $7.00 for every $1.00 spent in services and supplies. Per $1.00 spent, injectable contraceptives yielded savings of $5.60; oral contraceptives, $4.07; the patch, $2.99; the vaginal ring, $2.55; barrier methods, $1.34; and emergency contraceptives, $1.43. CONCLUSIONS: All contraceptive methods were cost-effective-they saved more in public expenditures for unintended pregnancies than they cost to provide. Because no single method is clinically recommended to every woman, it is medically and fiscally advisable for public health programs to offer all contraceptive methods.

Uterine artery embolization in postabortion hemorrhage.

OBJECTIVE: To summarize the efficacy of postabortion uterine artery embolization in cases of refractory hemorrhage. METHODS: Forty-two women were identified who had postabortion uterine artery embolization at San Francisco General Hospital between January 2000 and August 2007. Seven underwent embolization for hemorrhage caused by abnormal placentation. RESULTS: Embolization was successful in 90% (38 of 42) of cases. All failures (n=4) were in patients who had confirmed abnormal placentation. However, three of seven women (43%) with probable accreta diagnosed by ultrasonography were treated successfully with uterine artery embolization. Two patients experienced complications of uterine artery embolization. These complications-one contrast reaction and one femoral artery embolus-were treated without further sequelae. CONCLUSION: Uterine artery embolization is an alternative to hysterectomy in patients with postabortion hemorrhage refractory to conservative measures, especially when hemorrhage is caused by uterine atony or cervical laceration.

Challenges in translating evidence to practice: the provision of intrauterine contraception.

OBJECTIVE: Intrauterine contraception is used by many women worldwide, however, it is rarely used in the United States. Although available at no cost from the state family planning program for low-income women in California, only 1.3% of female patients obtain intrauterine contraceptives annually. This study assessed knowledge and practice patterns of practitioners regarding intrauterine contraception. METHODS: We conducted a survey among physicians, nurse practitioners, and physician assistants (n=1,246) serving more than 100 contraceptive patients per year in the California State family planning program. The response rate was 65% (N=816). We used multiple logistic regression to measure the association of knowledge with clinical practice among different provider types. RESULTS: Forty percent of providers did not offer intrauterine contraception to contraceptive patients, and 36% infrequently provided counseling, although 92% thought their patients were receptive to learning about the method. Regression analyses showed younger physicians and those trained in residency were more likely to offer insertions. Fewer than half of clinicians considered nulliparous women (46%) and postabortion women (39%) to be appropriate candidates. Evidence-based views of the types of patients who could be safely provided with intrauterine contraception were associated with more counseling and method provision, as well as with knowledge of bleeding patterns for the levonorgestrel-releasing intrauterine system and copper devices. CONCLUSION: Prescribing practices reflected the erroneous belief that intrauterine contraceptives are appropriate only for a restricted set of women. The scientific literature shows intrauterine contraceptives can be used safely by many women, including postabortion patients. Results revealed a need for training on updated insertion guidelines and method-specific side effects, including differences between hormonal and nonhormonal devices. LEVEL OF EVIDENCE: III.

Predictors of abortion provision among practicing obstetrician-gynecologists: a national survey.

OBJECTIVE: The objective of the study was to identify the factors that predict whether physicians include pregnancy termination in their practices. STUDY DESIGN: We surveyed all 5055 obstetrician-gynecologists who became board certified between 1998 and 2001 about personal characteristics, career plans, intention to provide abortions before residency, residency training, and current abortion practice. RESULTS: Of 2149 respondents (43%), 22% had provided elective abortion in the past year. In multivariate analysis controlling for preresidency intentions, personal beliefs, and other variables, the following were independently associated with current abortion provision: completing a residency program with abortion training (odds ratio [OR], 1.6; confidence interval [CI], 1.1-2.3; P = .007) and performing a greater number of abortions during residency (>25 abortions: OR, 2.8; CI, 1.9-4.1; P < .001). Factors negatively associated with working in a practice (OR, 0.4; CI, 0.2-0.6; P < .001) or hospital (OR, 0.4; CI, 0.3-0.6; P < .001) that prohibits abortion. CONCLUSION: Regardless of intention to provide abortion before residency, abortion training availability was positively correlated with providing abortion in future practice.

Predictors of delay in each step leading to an abortion.

BACKGROUND: Approximately 1 out of 10 abortions in the United States occurs in the second trimester of pregnancy. This study uses survival analysis to identify the factors which delay each step of the process of obtaining an abortion. STUDY DESIGN: This is a secondary data analysis of a cross-sectional study investigating a sample of 398 women who presented for elective abortion at an urban hospital. Respondents completed a survey using an audio-assisted self-interviewing program and provided a timeline for their process of obtaining an abortion. RESULTS: In our analysis, we divided the abortion process into three steps ending in three distinct events (first pregnancy test, calling a clinic, getting an abortion). Factors associated with delay during the first step include obesity [hazard ratio (HR) 0.8, 95% CI 0.6-1.0], abuse of drugs or alcohol (HR 0.7, 95% CI 0.6-1.0), prior second-trimester abortion (HR 0.6, 95% CI 0.4-0.8) and being unsure of last menstrual period (HR 0.6, 95% CI 0.4-0.7) and emotional factors such as being in denial (HR 0.8, 95% CI 0.6-1.0) and fear of abortion (HR 0.7, 95% CI 0.5-1.0). CONCLUSION: This study identified key factors associated with delay in obtaining abortion care. Interventions which seek to address these factors, especially those factors associated with later pregnancy suspicion and testing, may reduce abortion delay and facilitate women obtaining their abortions when medical risk and overall cost are lower.

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.

Effectiveness and safety of early medication abortion provided in pharmacies by auxiliary nurse-midwives: A non-inferiority study in Nepal.

BACKGROUND: Expanding access to medication abortion through pharmacies is a promising avenue to reach women with safe and convenient care, yet no pharmacy provision interventions have been evaluated. This observational non-inferiority study investigated the effectiveness and safety of mifepristone-misoprostol medication abortion provided at pharmacies, compared to government-certified public health facilities, by trained auxiliary nurse-midwives in Nepal. METHODS: Auxiliary nurse-midwives were trained to provide medication abortion through twelve pharmacies and public facilities as part of a demonstration project in two districts. Eligible women were ≤63 days pregnant, aged 16-45, and had no medical contraindications. Between 2014-2015, participants (n = 605) obtained 200 mg mifepristone orally and 800 µg misoprostol sublingually or intravaginally 24 hours later, and followed-up 14-21 days later. The primary outcome was complete abortion without manual vacuum aspiration; the secondary outcome was complication requiring treatment. We assessed risk differences by facility type with multivariable logistic mixed-effects regression. RESULTS: Over 99% of enrolled women completed follow-up (n = 600). Complete abortions occurred in 588 (98·0%) cases, with ten incomplete abortions and two continuing pregnancies. 293/297 (98·7%) pharmacy participants and 295/303 (97·4%) public facility participants had complete abortions, with an adjusted risk difference falling within the pre-specified 5 percentage-point non-inferiority margin (1·5% [-0·8%, 3·8%]). No serious adverse events occurred. Five (1.7%) pharmacy and two (0.7%) public facility participants experienced a complication warranting treatment (aRD, 0.8% [-1.0%-2.7%]). CONCLUSIONS: Early mifepristone-misoprostol abortion was as effective and safe when provided by trained auxiliary nurse-midwives at pharmacies as at government-certified health facilities. Findings support policy expanding provision through registered pharmacies by trained auxiliary nurse-midwives to improve access to safe care.