Assessing Acceptability of Biodegradable Contraceptive Implants in Kenya and Senegal.

BACKGROUND: Contraceptive implants are popular in Africa, but barriers to removal exist. Biodegradable implants (BDIs) offer an alternative to the need for removal. This study explored potential user, provider, and other stakeholder perspectives on 2 BDI prototypes, revealing opportunities and challenges for introduction. METHODS: We conducted focus group discussions (FGDs) and in-depth interviews (IDIs) with women, men, family planning (FP) providers, community influencers, and FP policymakers and program staff in Kenya and Senegal. Characteristics of the 2 BDI prototypes were shared, and participants held and interacted with placebo prototypes. Structural coding was used to analyze the data focused on key product attributes, including biodegradation, removal potential, size, material, insertion site, and duration of effectiveness. RESULTS: We conducted 16 FGDs and 35 IDIs with 106 participants in Kenya and 15 FGDs and 43 IDIs with 102 participants in Senegal. Overall, respondents liked the idea of a BDI, noting the avoidance of pain and scarring and reduced transport and costs as benefits of no removal requirement. Kenyan respondents expressed greater understanding of the biodegradation process than those in Senegal, though potential users in both countries expressed concerns about possible side effects associated with the process. In Senegal, mention of cholesterol in a BDI caused concern, while Kenyan participants responded positively to the same BDI being composed of organic materials. The second BDI product was viewed as more similar to existing implants, which providers preferred. Participants suggested increasing the pregnancy protection duration beyond 18 months. No clear preference between products emerged, and participants liked and disliked some characteristics of both. CONCLUSIONS: Kenyan and Senegalese participants expressed interest in the BDI concept but expressed some reservations related to biodegradation, material, and side effects. BDIs offer the opportunity to expand contraceptive choice. However, messaging around product characteristics will be required for successful introduction and uptake.

Neighborhood-level racialized socioeconomic deprivation and contraceptive use in the United States, 2011-2019.

INTRODUCTION: The social and structural environments where people live are understudied in contraceptive research. We assessed if neighborhood measures of racialized socioeconomic deprivation are associated with contraceptive use in the United States. METHODS: We used restricted geographic data from four waves of the National Survey of Family Growth (2011-2019) limited to non-pregnant women ages 15-44 who had sex in the last 12 months. We characterized respondent neighborhoods (census tracts) with the Index of Concentration at the Extremes (ICE), a measure of spatial social polarization, into areas of concentrated privilege (predominantly white residents living on high incomes) and deprivation (predominantly people of color living on low incomes). We used multivariable binary and multinomial logistic regression with year fixed effects to estimate adjusted associations between ICE tertile and contraceptive use and method type. We also assessed for an interactive effect of ICE and health insurance type. RESULTS: Of the 14,396 respondents, 88.4% in neighborhoods of concentrated deprivation used any contraception, compared to 92.7% in the most privileged neighborhoods. In adjusted models, the predicted probability of using any contraception in neighborhoods of concentrated deprivation was 2.8 percentage points lower than in neighborhoods of concentrated privilege, 5.0 percentage points higher for barrier/coital dependent methods, and 4.3 percentage points lower for short-acting methods. Those with Medicaid were less likely to use any contraception than those with private insurance irrespective of neighborhood classification. CONCLUSIONS: This study highlights the salience of structural factors for contraceptive use and the need for continued examination of structural oppressions to inform health policy.

Potential demand for and access to medication abortion among North Carolina college students.

OBJECTIVE: To estimate demand for medication abortion (MAB) among North Carolina (NC) college students and describe access to nearest clinics offering MAB to each campus. METHODS: We calculated demand using 2019-2020 campus demographics and NC abortion statistics. We used a mystery client technique to gather MAB cost and appointment wait times at the closest clinics and calculated travel distances and times. RESULTS: We estimated that 2,517 NC students seek MAB annually. Twenty-one clinics were closest to NC's 111 colleges and universities, including five in neighboring states. Mean cost was $450, with an average wait time of six days to appointment. The average round-trip travel distance was 58 miles and time to the nearest clinic was 84 min by car. CONCLUSIONS: Many NC college students likely obtain MAB every year and face high costs, long wait times and distances to care, which has likely worsened after the overturning of Roe v. Wade.

Separating Procedure-related Fears From Future Fertility Concerns Among a Cohort Seeking Abortion Information Online.

INTRODUCTION: The general public and abortion patients in the United States have misinformation about the risks of infertility associated with abortion, which may influence abortion care-seeking. METHODS: The Google Ads Abortion Access Study was a national study of people considering abortion and searching online for information. Participants completed baseline and follow-up surveys, providing free text responses to questions about barriers and facilitators to abortion. We conducted an exploratory analysis of the free text responses related to fertility and used thematic analysis to identify concerns raised about links between abortion and future fertility. RESULTS: Of 864 participants who provided free text responses in the follow-up survey, 32 specifically mentioned fertility. Few expressed fear that complications from the abortion procedure would somehow lead to infertility; rather, most discussed complex and overlapping thoughts about how abortion factored into their reproductive life plans. These included age-related concerns, missing out on their "chance" to have a child, fear of being punished by God with infertility for having an abortion, and conflicting emotions if they had previously been told they were subfecund or infertile. CONCLUSION: Although previous research has focused on misinformation about the link between abortion and infertility, participants in this study rarely mentioned it as a concern. Researchers and practitioners should be attuned to the distinctions people make between infertility occurring as a result of abortion and other fears they might have about not achieving their future reproductive aspirations, ask questions, and provide counseling accordingly.

Perspectives on sexual and reproductive health self-care among women, healthcare providers, and other key informants: a mixed-methods study in South Africa and Zambia.

BACKGROUND: "Self-care" for sexual and reproductive health (SRH) includes contraceptive methods and other supplies that people can use with or without the support of a healthcare provider. Self-administered tests, self-injection of injectable contraception, or self-removal of intrauterine devices (IUDs) can increase people's access to and autonomy over their own SRH. Objectives of this study were to assess women's current interest in and use of SRH self-care and explore key informants' (KI) opinions of self-care, especially during the COVID-19 pandemic. METHODS: Data for this study came from female participants in the longitudinal Contraceptive Use Beyond ECHO (CUBE) study, and KIs, including healthcare providers, in South Africa and Zambia between September 2020 and June 2021. For this analysis, we used data from a participant phone survey (n = 537), and from in-depth interviews (IDIs) completed with a sub-sample of women (n = 39) and KIs (n = 36). Survey data were analyzed with descriptive statistics, and IDI data were analyzed using applied thematic analysis. RESULTS: Female survey participants in South Africa were more interested in learning about emergency contraceptive pills, subcutaneous injectable contraception, and CycleBeads, while Zambian participants wanted more information and access to condoms. However, in IDIs in both countries, women described minimal experience with self-care beyond condom use. In the Zambian KI IDIs, COVID-19 led to increased self-care counseling on subcutaneous injectable contraception and HIV self-testing. KIs who do not counsel on self-care were concerned that women may harm themselves or blame the provider for difficulties. Two KIs thought that women could possibly self-remove IUDs, but most expressed concerns. Reported barriers to self-care included COVID movement restrictions, transport costs, lack of accessible pharmacies, women's low awareness, and possible stigma. CONCLUSIONS: Women surveyed reported interest in learning more about SRH self-care methods and resources, but in IDIs did not report extensive previous use besides condoms. KIs described some concerns about women's ability to use self-care methods. Counseling on and provision of self-care methods and supplies may have increased during the COVID-19 pandemic, but ensuring that self-care is more than just a temporary measure in health systems has the potential to increase access to SRH care and support women's autonomy and healthcare needs.

BACKGROUND: "Self-care" refers to healthcare that does not have to be given by a provider, but that people can use themselves. In sexual and reproductive health (SRH), this includes medicines or supplies like pills and injections that people can use to prevent or test for pregnancy or sexually transmitted infections. This study wanted to better understand women's interest in and use of SRH self-care and explore key informants' opinions of self-care, especially during the COVID-19 pandemic. METHODS: We surveyed 537 women in KwaZulu-Natal province, South Africa and Lusaka, Zambia in 2020­2021. We also conducted interviews with 39 women and 36 key informants, including healthcare providers, government officials, and community advocates. RESULTS: Women surveyed in South Africa were more interested than those in Zambia in learning more about self-care contraception, especially daily pills, emergency pills, and injections they could give themselves. In interviews, some key informants said that they do not tell women about self-care because they worried that women could hurt themselves or blame the provider if they experienced problems. COVID movement restrictions, transport costs, and inaccessible pharmacies were all barriers that key informants mentioned to accessing tests, tools, or contraceptive methods that women could give or use themselves. CONCLUSIONS: Women surveyed were interested in learning more about self-care and those interviewed reported minimal previous use of self-care methods besides condoms. Providers also have some concerns about women's ability to use self-care methods. Counseling on and providing self-care methods and supplies may have increased during COVID-19, but increasing access to self-care could help more women take care of their own sexual and reproductive healthcare.

Prevalence and County-Level Distribution of Births in Catholic Hospitals in the US in 2020.

This study uses American Hospital Association data to examine the volume and distribution of births in Catholic US hospitals and quantify county-level patterns of Catholic and non-Catholic hospital births.

Contraceptive Continuation and Experiences Obtaining Implant and IUD Removal Among Women Randomized to Use Injectable Contraception, Levonorgestrel Implant, and Copper IUD in South Africa and Zambia.

Few longitudinal studies have measured contraceptive continuation past one year in sub-Saharan Africa. We surveyed 674 women who had been randomized to receive the three-month intramuscular contraceptive injectable (DMPA-IM), levonorgestrel (LNG) implant, or copper intrauterine device (IUD) during the Evidence for Contraceptive Options and HIV Outcomes (ECHO) trial in South Africa and Zambia and were subsequently followed for two additional years to explore method continuation, reasons for discontinuation, and access to implant and IUD removal services. We also conducted in-depth qualitative interviews with 39 participants. We estimated cumulative discontinuation probabilities using Kaplan-Meier estimates and assessed factors associated with discontinuation using Cox-proportional hazards models. The LNG implant continuation rate over the maximum 44-month study period was 60 percent, while rates for the copper IUD and DMPA-IM were 52 percent and 44 percent, respectively. Reasons for method discontinuation included side effects, particularly menstrual changes, and method stock-outs. Most implant and IUD users who sought removal were able to access services; however, room for improvement exists. In this cohort originally randomized to receive a contraceptive method and attend regular study visits, implants and IUDs continued to be highly acceptable over an additional two years, but facilities should continue to ensure that insertions and removals are available as requested.

Fear of procedure and pain in individuals considering abortion: A qualitative study.

OBJECTIVES: To explore concerns about procedural abortion and abortion-related pain in a cohort searching for abortion online. METHODS: The Google Ads Abortion Access Study was a national longitudinal cohort study that recruited people searching for abortion online. Participants completed a baseline demographic survey and a follow-up survey four weeks later evaluating barriers and facilitators to abortion. This qualitative study utilized thematic analysis to produce a descriptive narrative based on overarching themes about procedural abortion and abortion-related pain. RESULTS: There were 57 separate mentions from 45 participants regarding procedural abortion or abortion-related pain. We identified two main themes: 1) concerns about the procedure (with subthemes, fear of procedural abortion, comparison to medication abortion, lack of sedation) and 2) abortion-related pain (with subthemes fear of abortion-related pain, experiences of pain, fear of complications and cost-barriers to pain control). CONCLUSIONS: This study highlights the need for improved anticipatory guidance and accessible resources to assuage potential fears and misconceptions regarding abortion. PRACTICE IMPLIACTIONS: Abortion resources, particularly online, should provide accurate and unbiased information about abortion methods and pain to help patients feel more prepared. Providers should be aware of potential concerns surrounding procedural abortion and pain when counseling patients presenting for care.

Is long-acting reversible contraceptive method use associated with HIV testing frequency in KwaZulu-Natal, South Africa and Lusaka, Zambia? Findings from the CUBE study.

Objectives: To assess differences in HIV testing at 6-months intervals over 24 months among intramuscular depot medroxyprogesterone acetate (DMPA-IM) injectable, levonorgestrel implant, or copper intrauterine devices (IUD) users in KwaZulu-Natal, South Africa, and Lusaka, Zambia. Testing at recommended intervals has not been previously assessed in long-acting reversible contraceptive (LARC) users (implant and IUD users) compared to those using effective but shorter-acting methods (such as DMPA-IM) in sub-Saharan Africa. Study design: As part of the longitudinal contraceptive use beyond ECHO (CUBE) study, we measured HIV testing over 24 months. Participants were considered continuous users of DMPA-IM, levonorgestrel implant, or copper IUD if they used the same method across all months of their study participation, or not continuous users of their baseline CUBE method if they switched or discontinued their method. We used multivariable logistic regression models with generalized estimating equations and robust standard errors, stratified by country, to assess differences in HIV testing. Results: Among the 498 participants, HIV testing rates were higher in Zambia for all methods compared to South Africa. In bivariate analyses, continuous implant or IUD users (the LARC users) were significantly less likely to report having received HIV testing at the 6-months and 24-months surveys, compared to continuous DMPA-IM users. In adjusted longitudinal models, continuous IUD users (adjusted odds ratio: 0.42, 95% CI: 0.24, 0.74), continuous implant users (adjusted odds ratio: 0.23, 95% CI: 0.12, 0.42) in South Africa had significantly lower odds of HIV testing compared to continuous DMPA-IM users. There were no significant differences in Zambia in the adjusted models. Conclusion: LARC use may reduce opportunities for HIV testing and users should be counseled on regular HIV testing and the option of HIV self-testing. Implications: Due to infrequent clinical contacts which may lead to lower rates of HIV testing at recommended intervals, LARC users should be provided opportunities to test for HIV at home or when seeking other health services.

Association Between Distance to an Abortion Facility and Abortion or Pregnancy Outcome Among a Prospective Cohort of People Seeking Abortion Online.

Importance: Many people face barriers to abortion care, including long distances to an abortion facility. Objectives: To investigate the association of distance to the nearest abortion facility with abortion or pregnancy outcome. Design, Setting, and Participants: This cohort study was conducted using data from the Google Ads Abortion Access study, a prospective cohort study of individuals considering abortion recruited between August 2017 and May 2018. Individuals from 50 states and Washington, District of Columbia, who were pregnant and considering abortion based on self-report were recruited online using a stratified sampling technique. Participants completed online baseline and 4-week follow-up surveys. Data were analyzed between May and August 2021. Exposures: Driving distance to an abortion facility calculated from participant zip code and grouped into 4 categories (<5 miles, 5-24 miles, 25-49 miles, and ≥50 miles). Main Outcomes and Measures: Abortion or pregnancy outcome reported at 4-week follow-up, categorized as had an abortion, still seeking an abortion, or planning to continue pregnancy. Other measures included reported experience of 8 distance-related barriers to abortion, such as having to gather money for travel expenses and having to keep the abortion a secret. Results: Among 1485 pregnant individuals considering abortion who completed the baseline survey and provided contact information, 1005 individuals completed follow-up (follow-up rate, 67.7%) and 856 participants were included in the analytic sample (443 individuals ages 25-34 years [51.8%]; 208 Black individuals [24.3%]; 101 Hispanic or Latinx individuals [11.8%], and 468 White individuals [54.8%]). Most participants had at least some college education (474 individuals [55.5%]). Distance to an abortion facility was less than 5 miles for 233 individuals (27.2%), 5 to 24 miles for 373 individuals (43.6%), 25 to 49 miles for 85 individuals (9.9%), and 50 or more miles for 165 individuals (19.3%) (mean [SD] distance = 28.3 [43.8] miles). Most participants reported at least 1 distance-related barrier (763 individuals [89.1%]), with a mean of 3.3 barriers (95% CI, 3.2-3.5 barriers) reported. For 7 of 8 distance-related barriers, an increased percentage of participants living farther from an abortion facility reported the barrier compared with participants living less than 5 miles from a facility; for example, 61.8% (95% CI, 53.5%-69.4%) of individuals living less than 5 miles reported having to gather money for travel expenses, while 81.2% (95% CI, 70.8%-88.5%; P = .002) of those living 25 to 49 miles and 75.8% (95% CI, 69.9%-81.0%; P = .02) of those living 50 or more miles from a facility reported this barrier. At follow-up, participants living 50 or more miles from a facility had higher odds of still being pregnant and seeking abortion (adjusted odds ratio [aOR] = 2.07; 95% CI, 1.35-3.17; P = .001) or planning to continue pregnancy (aOR = 1.96; 95% CI, 1.06-3.63; P = .03) compared with participants living within 5 miles. Conclusions and Relevance: This study found that greater distance from an abortion facility was associated with delays in obtaining abortion care and inability to receive abortion care. These findings suggest that innovative approaches to abortion provision may be needed to mitigate outcomes associated with long distances to abortion facilities.

mHealth Interventions for Contraceptive Behavior Change in the United States: A Systematic Review.

Ensuring people have access to their preferred method of contraception can be key for meeting their reproductive goals. A growing number of mHealth interventions show promise for improving access to contraception, but no literature review has identified the effects of mHealth interventions among both adolescents and adults in the United States. The purpose of this systematic review was to describe the format, theoretical basis, and impact of mHealth interventions for contraceptive behavior change (contraceptive initiation and continuation) among people of all ages in the US. A systematic review of the literature was conducted using six electronic databases guided by Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines. Data on study design, frequency, duration, mHealth modality, contraceptive method, behavior change theory, and behavioral outcome were extracted to facilitate comparison. Eighteen studies met eligibility criteria. The majority (11; 61%) used SMS (short message service). Twelve studies focused on contraceptive initiation, most (n = 8) of which also measured continued use over time. The remaining six interventions focused on continuation alone, generally through appointment reminders. Very little contraceptive behavior change was identified across studies. Current mHealth interventions may hold promise for some health areas but there is little evidence that they change contraceptive behavior. Future mHealth interventions should focus on assessing person-centered outcomes, including satisfaction, side effects, and reasons for discontinuation, to best support people to use their preferred contraceptive method.

Barriers to abortion care and incidence of attempted self-managed abortion among individuals searching Google for abortion care: A national prospective study.

OBJECTIVE: Studies on self-managed abortion conducted at abortion clinics may exclude those facing the greatest barriers to care. We aimed to assess association of attempted self-managed abortion with reported barriers to abortion care. STUDY DESIGN: We used data from the Google Ads Abortion Access Study, a prospective cohort study that recruited people searching for abortion care on Google between August 2017 and April 2018. We used a stratified sampling design recruiting by state to ensure representation from all 50 states. Participants completed an online baseline survey and follow-up 4 weeks later. We modeled the adjusted odds of attempting self-managed abortion using multivariable logistic regression, with random effects for state of residence. We assessed attempted self-managed abortion at follow-up by asking: "Did you take or try to do any of the following to try to end this pregnancy?" with a closed-ended list of methods. RESULTS: Among 856 participants with follow-up data, 28% (95% confidence interval [95% CI]: 25%-31%) reported attempting self-managed abortion. Most common methods used were: herbs, supplements, or vitamins (52%); emergency contraception or many contraceptive pills (19%); mifepristone and/or misoprostol (18%); and abdominal or other physical trauma (18%). Participants still seeking abortion at 4 weeks were more likely to attempt self-management (33%) than those planning to carry to term (20%, p < 0.001). Reporting having to keep the abortion a secret, fearing for one's safety/well-being, needing to gather money for travel or the abortion, or living further from an abortion facility as barriers were associated with higher odds of attempts. CONCLUSIONS: Attempted self-managed abortion is higher among people facing barriers to abortion care. IMPLICATIONS: Reducing financial and distance barriers, such as by removing legal restrictions on abortion, could help reduce attempted self-managed abortion. Additionally, removing restrictions on telehealth for abortion could reduce attempted self-managed abortion. Efforts are needed to permanently remove United States Food and Drug Administration (FDA) regulations and state policies prohibiting telehealth for medication abortion, thereby allowing individuals to end their pregnancies without a clinic visit.

Pregnancy outcomes after exposure to crisis pregnancy centers among an abortion-seeking sample recruited online.

INTRODUCTION: More than 2,500 crisis pregnancy centers (CPCs), which seek to convince people considering abortion to continue their pregnancies, exist in the United States. However, the characteristics of people who visit CPCs and their pregnancy outcomes are largely unknown. This study sought to describe the characteristics of people considering abortion who report visiting CPCs, and whether CPC visit is associated with abortion or continuing the pregnancy 4 weeks later. METHODS: Between August 2017 to May 2018, we recruited pregnant people searching for abortion services online, and 857 participants completed baseline and 4-week follow-up surveys. We described characteristics associated with visiting a CPC and compared pregnancy and abortion outcomes for those who reported CPC visit to those who did not using mixed-effects multivariable logistic regression. RESULTS: Overall, 13.1% of respondents visited a confirmed CPC. Living further away from a CPC was associated with lower odds of a CPC visit. At follow-up, respondents who had visited a CPC were significantly less likely to have had an abortion (29.5%) than those who had not visited a CPC (50.5%). In the adjusted models, respondents who had visited a CPC had higher odds of being pregnant and still seeking abortion (aOR: 2.26, 95% CI: 1.37-3.73) or continuing the pregnancy (aOR: 2.35, 95% CI: 1.33-4.15) (versus having had an abortion), than those who had not visited a CPC. CONCLUSIONS: CPCs may be providing resources to people who are considering continuing their pregnancy and/or they may be misleading people about the care and referrals they provide related to abortion. Pregnant people need access to accurate information, decision support, and resources to make the pregnancy or abortion decision that is best for them.

Corrigendum to "Using Google Ads to recruit and retain a cohort considering abortion in the United States" [Contraception: X (2) (2020) 100017].

[This corrects the article DOI: 10.1016/j.conx.2019.100017.].

Abortion Waiting Periods and Decision Certainty Among People Searching Online for Abortion Care.

OBJECTIVE: Many U.S. states mandate counseling and a waiting period before abortion, which often necessitates two separate clinic visits. These laws purport to ensure individuals are certain about their abortion decision. We examined whether exposure to these laws is associated with increased decision certainty. METHODS: The Google Ads Abortion Access Study is a prospective study of pregnant people considering abortion recruited when searching online using abortion care-related keywords. Eligible participants, who represented all 50 U.S. states, completed baseline and 4-week follow-up surveys. We measured decision certainty using the Decisional Conflict Scale (scores range from 0 to 100; higher scores reflect lower certainty). We used a multivariable linear mixed model to examine the association between living in states with waiting periods, two-visit requirements, or both and changes in decision certainty. We also compared baseline, follow-up, and changes in decision certainty by whether the pregnancy was ongoing or not at follow-up. RESULTS: The analytic sample included 750 participants who contributed relevant baseline and follow-up data. At follow-up, 396 participants had an abortion, and 354 had not. There was no significant increase in decision certainty for participants in states with waiting period laws (mean change score -1.0, 95% CI -2.8 to 2.8). In adjusted models, still seeking an abortion at 4-week follow-up was associated with decreased certainty (mean change score 8.05, 95% CI 5.13-10.97). Those still seeking abortion had significantly lower certainty (baseline score 28.8 and follow-up score 32.2) than those who had obtained an abortion (baseline score 21.8 and follow-up score 20.1, P<.01). CONCLUSION: Decision certainty is relatively high and stable over time among those who had had an abortion. Living in a state with a waiting period or two-visit requirement is not associated with increased decision certainty.

State abortion policies and Medicaid coverage of abortion are associated with pregnancy outcomes among individuals seeking abortion recruited using Google Ads: A national cohort study.

OBJECTIVE: A major challenge to understanding barriers to abortion is that those individuals most affected may never reach an abortion provider, making the full impact of restrictive policies difficult to measure. The Google Ads Abortion Access Study used a novel method to recruit individuals much earlier in the abortion-seeking process. We aimed to understand how state-level abortion policies and Medicaid coverage of abortion influence individuals' ability to obtain wanted abortions. METHODS: We employed a stratified sampling design to recruit a national cohort from all 50 states searching Google for abortion care. Participants completed online baseline and 4-week follow-up surveys. The primary independent variables were: 1) state policy environment and 2) state coverage of abortion for people with Medicaid. We developed multivariable multinomial mixed effects models to estimate the associations between each state-level independent variable and pregnancy outcome. RESULTS: Of the 874 participants with follow-up data, 48% had had an abortion, 32% were still seeking an abortion, and 20% were planning to continue their pregnancies at 4 weeks follow-up. Individuals in restricted access states had significantly higher odds of planning to continue the pregnancy at follow-up than participants in protected access states (aOR = 1.70, 95% CI = 1.08, 2.70). Individuals in states that do not provide coverage of abortion for people with Medicaid had significantly higher odds of still seeking an abortion at follow-up (aOR = 1.80, 95% CI = 1.24, 2.60). Individuals living in states without Medicaid coverage were significantly more likely to report that having to gather money to pay for travel expenses or for the abortion was a barrier to care. CONCLUSIONS: Restrictive state-level abortion policies are associated with not having an abortion at all and lack of coverage for abortion is associated with prolonged abortion seeking. Medicaid coverage of abortion appears critical to ensuring that all people who want abortions can obtain them.

Factors Associated With Delayed Contraceptive Implant Removal in Ethiopia.

BACKGROUND: In 2009, the Government of Ethiopia initiated the implant scale-up initiative, which expanded contraceptive access by training health extension workers (HEWs) to insert single-rod etonogestrel contraceptive implants (Implanon) at rural health posts. Removals were provided by referrals to higher levels of the health system. However, little was known about whether women were getting their implants removed at the recommended 3-year postinsertion date or what barriers they faced to removal. METHODS: Between June and July 2016, 1,860 Ethiopian women, who had a 1-rod etonogestrel implant inserted by either an HEW or another health care provider between 3 and 6 years prior, were surveyed. We describe the characteristics of the sample and use multivariable logistic regression to predict factors associated with keeping implants inserted beyond 3 years. RESULTS: Women who had received their implants from HEWs were significantly more likely to report keeping them inserted for more than 3 years (adjusted odds ratio=2.50; 95% confidence interval=1.19, 5.24), compared with those who got their implant from another health care provider. Women who reported distance to the facility or transportation as a barrier were also significantly more likely to keep their implant for more than 3 years. Married and educated women were less likely to keep their implants for an extended duration. Among women who had their implant for 3 years or less, women who had had it inserted by an HEW were significantly more likely to report that the provider was unable or refused to provide removal as a barrier. DISCUSSION: Efforts to expand lower level and community-based access to contraceptive implants that do not ensure reliable access to removals at the same level as insertions may lead to women using implants beyond the recommended duration.

What About Methods for Men? A Qualitative Analysis of Attitudes Toward Male Contraception in Burkina Faso and Uganda.

CONTEXT: Male contraceptive options are limited; however, product development efforts tend to focus on female methods. Research on attitudes toward methods for men-particularly in regions of low contraceptive prevalence, such as Sub-Saharan Africa-could inform the development of new male methods. METHODS: Qualitative data were taken from focus group discussions with 80 men aged 23-67 and 398 women aged 15-50 conducted in Burkina Faso and Uganda in 2016. Transcripts were analyzed thematically to explore support among men and women for male contraceptive methods, and to extract suggestions about ideal method characteristics. RESULTS: Male and female participants in both countries expressed support for new male contraceptive options; more positive attitudes were expressed in Uganda than in Burkina Faso. Participants of both sexes recognized that male methods could reduce the family planning burden on women and offer men greater control over their fertility; however, some had concerns about side effects and thought that men would not use contraceptives. Relationship characteristics, such as polygamous unions, were cited as possible challenges. In both countries, various delivery methods (e.g., creams or jellies, injections and implants) and durations (from short-acting to permanent) were proposed. CONCLUSIONS: The acceptability of new male methods among most participants in the two countries indicates a potential demand for male contraceptives. Options should include a variety of method characteristics to maximize choice, engage men, and support men and women's contraceptive needs.

RESUMEN Contexto: Las opciones de anticonceptivos masculinos son limitadas; sin embargo, los esfuerzos de desarrollo de productos tienden a enfocarse en los métodos femeninos. La investigación sobre las actitudes hacia los métodos para hombres, ­ particularmente en las regiones de baja prevalencia de anticoncepción, como el África subsahariana­ podría dar sustento al desarrollo de nuevos métodos masculinos. Métodos: Se tomaron datos cualitativos a partir de discusiones de grupos focales que se llevaron a cabo en Burkina Faso y Uganda en 2016, con la participación de 80 hombres de 23 a 67 años y de 398 mujeres de 15 a 50 años. Las transcripciones se analizaron temáticamente para explorar el apoyo de hombres y mujeres a los métodos anticonceptivos masculinos, así como para extraer sugerencias sobre las características ideales del método. Resultados: Los participantes masculinos y femeninos en ambos países expresaron su apoyo a las nuevas opciones de anticonceptivos masculinos; se expresaron más actitudes positivas en Uganda que en Burkina Faso. Los participantes de ambos sexos reconocieron que los métodos masculinos podrían reducir la carga de planificación familiar para las mujeres y ofrecer a los hombres un mayor control sobre su fecundidad; sin embargo, algunos participantes plantearon sus preocupaciones sobre los efectos secundarios y consideraron que los hombres no usarían anticonceptivos. Las características de la relación, como las uniones polígamas, se mencionaron como posibles desafíos. En ambos países, se propusieron varios tipos de métodos anticonceptivos (por ejemplo, cremas o jaleas, la inyección y el implante) y de distintas duraciones (de acción corta a permanente). Conclusiones: La aceptabilidad de los nuevos métodos masculinos en la mayoría de los participantes en los dos países indica una demanda potencial de anticoncepción masculina. Las opciones deberían incluir una variedad de características del método para maximizar la elección, involucrar a los hombres y apoyar las necesidades de anticonceptivos de hombres y mujeres.

RÉSUMÉ Contexte: Les options contraceptives masculines ne sont guère nombreuses. Le fait est, cependant, que les efforts de développement de produits se concentrent généralement sur les méthodes féminines. L'étude des attitudes à l'égard des méthodes masculines ­ en particulier dans les régions à faible prévalence contraceptive telles que l'Afrique subsaharienne ­ permettrait d'éclairer le développement de nouvelles méthodes pour les hommes. Méthodes: Les données qualitatives requises ont été extraites de discussions de groupe menées en 2016 avec 80 hommes âgés de 23 à 67 ans et 398 femmes âgées de 15 à 50 ans au Burkina Faso et en Ouganda. Elles ont été transcrites et analy-sées thématiquement pour examiner le soutien des hommes et des femmes à l'égard des méthodes contraceptives masculines et en dégager les suggestions possibles sur les caractéristiques des méthodes idéales. Résultats: Dans les deux pays, les participants et participantes ont exprimé leur appui de nouvelles options de contraception masculine; plus d'attitudes positives ont été exprimées en Ouganda qu'au Burkina Faso. Les participants des deux sexes ont reconnu que les méthodes masculines pourraient alléger la charge de la planification familiale portée par les femmes et offrir aux hommes un meilleur contrôle de leur fécondité. Certains s'inquiétaient cependant des effets secondaires et pensaient que les hommes n'utiliseraient pas les contraceptifs. Les caractéristiques de relation, telles que les unions polygames, ont été citées comme difficultés possibles. Dans les deux pays, différentes méthodes (par exemple, crèmes ou gels, injection ou implant) et durées (de courte à permanente) ont été proposées. Conclusions: L'acceptabilité de nouvelles méthodes masculines aux yeux de la plupart des participants dans les deux pays révèle une demande potentielle de contraception masculine. Les options proposées doivent inclure diverses caractéristiques de méthode pour maximiser le choix, engager les hommes et soutenir les hommes et les femmes dans leurs besoins contraceptifs.

Using Google Ads to recruit and retain a cohort considering abortion in the United States.

OBJECTIVE: The objective was to develop and test the feasibility of a methodology to recruit and retain individuals in the United States (US) who were considering abortion at the point of searching for an abortion clinic. STUDY DESIGN: We conducted the Google Ads Abortion Access Study, a national cohort study using a novel recruitment method - recruiting people searching for abortion care on Google. Advertisements for the study were displayed in search results. Users who clicked on the advertisement were directed to a landing page explaining the study and then to a screening form. Participants were eligible if they reported being pregnant and considering abortion. They completed an online baseline survey and 4 weeks later were invited by email or text message to complete a follow-up survey. RESULTS: Over the course of 8 months, we recruited a racially/ethnically and geographically diverse cohort considering an abortion using Google Ads. After removing fraudulent cases, we recruited 1706 respondents, and among these, 1464 (86%) provided contact information for follow-up. Among those providing contact information, 1005 completed the follow-up survey, resulting in a 69% follow-up rate. Older age, white race, higher education, difficulty meeting basic needs, being not religious/spiritual and having no previous births were associated with higher follow-up. Total cost of the ads was $31.99 per completed baseline + follow-up survey. CONCLUSION: Researchers can use online advertising to successfully recruit populations early in their abortion-seeking process to understand the barriers they face and how to improve abortion access. Disadvantages include high cost and a small potential for fraudulent data. IMPLICATIONS: Google Ads is a feasible tool to recruit and follow a diverse sample of individuals who are considering abortion for studies investigating the barriers they face in obtaining a wanted abortion.