Treating Mild Chronic Hypertension During Pregnancy: A Cost-Effectiveness Analysis.

OBJECTIVE: To assess the cost effectiveness of targeting a blood pressure of less than 140/90 mm Hg compared with 160/105 mm Hg. METHODS: A decision-analytic model was constructed to compare the treatment of chronic hypertension in pregnancy at mild-range blood pressures (140/90 mm Hg) with the treatment of chronic hypertension before 20 weeks of gestation at severe-range blood pressures (160/105 mm Hg) in a theoretical cohort of 180,000 patients with mild chronic hypertension. Probabilities, costs, and utilities were derived from literature and varied in sensitivity analyses. Primary outcomes included incremental cost per quality-adjusted life-year (QALY), cases of preeclampsia, preeclampsia with severe features, severe maternal morbidity (SMM), preterm birth, maternal death, neonatal death, and neurodevelopmental delay. The cost-effectiveness threshold was $100,000 per QALY. RESULTS: Treating chronic hypertension in a population of 180,000 pregnant persons at mild-range blood pressures, compared with severe-range blood pressures, resulted in 14,177 fewer cases of preeclampsia (43,953 vs 58,130), 11,835 of which were cases of preeclampsia with severe features (40,530 vs 52,365). This led to 817 fewer cases of SMM (4,375 vs 5,192), and 18 fewer cases of maternal death (102 vs 120). Treating at a lower threshold also resulted in 8,078 fewer cases of preterm birth (22,000 vs 30,078), which led to 26 fewer neonatal deaths (276 vs 302) and 157 fewer cases of neurodevelopmental delay (661 vs 818). Overall, treating chronic hypertension at a lower threshold was a dominant strategy that resulted in decreased costs of $600 million and increased effectiveness of 12,852 QALYs. CONCLUSION: Treating chronic hypertension at a threshold of mild-range blood pressures is a dominant (lower costs, better outcomes) and cost-effective strategy that results in fewer neonatal and maternal deaths compared with the standard treatment of treating at severe range blood pressures.

Public perceptions of abortion complications.

BACKGROUND: Misinformation contributes to the perception that abortion has substantial health risks, despite the known safety of medication and aspiration abortion. We lack detailed information about which health risks the public believes are most likely. OBJECTIVE: This study aimed to describe public perception of short- and long-term risks of abortion. STUDY DESIGN: We conducted a cross-sectional survey of US residents aged ≥18 years using Amazon Mechanical Turk (MTurk). We collected information regarding participant demographics, reproductive history, political views, and position on abortion restrictions. We provided participants with a list of 9 short-term and 15 long-term possible complications and asked them to indicate whether they occurred never (0%), very rarely (<1%), rarely (1%-5%), occasionally (5%-20%), or frequently (>20%) following abortion. We used descriptive statistics to understand our population demographics and to capture the perceived incidence of all complications. We created a binary indicator of answering all risk estimates incorrectly vs at least 1 estimate correctly, separately for all long-term possible complications, and the 2 short-term risks of infection and bleeding. We determined the proportion of individuals who responded incorrectly to all questions in each category and used multivariable logistic regression to identify factors associated with incorrect perceptions about the risks of abortion. RESULTS: For all listed complications, participant (N=1057) estimates of risk were higher than the known incidence. For both short-term risks of bleeding and infection, over 40% of participants reported that these outcomes occur occasionally or frequently. Similarly, for both long-term risks of depression and anxiety, over 60% of respondents reported that these outcomes occur occasionally or frequently after abortion. Participants reported that possible complications known to not be associated with abortion, including hair loss, future pregnancy complications, breast cancer, and cosmetic disfigurement, occurred at least rarely. Nearly one-quarter of participants responded that death occurs occasionally or frequently (in over 5% of abortions), and 79% of participants responded that breast cancer can result from abortion. One-quarter (24.9%) of participants incorrectly overestimated both short-term outcomes of infection and bleeding, whereas 19.5% answered all long-term complication questions incorrectly, including outcomes that never occur. On multivariable analyses, we identified that the participants most likely to incorrectly identify risks of abortion identified as Asian or Black race/ethnicity, were from rural communities, or believed that abortion should have more legal restrictions. CONCLUSION: The public perceives abortion to be much riskier than it actually is. This information can be used to develop targeted clinical and public health efforts to disseminate the true risks of abortion.

Preventing eviction during pregnancy: a cost-effectiveness analysis of a theoretical safety-net program.

BACKGROUND: Eviction during pregnancy has been shown to be associated with adverse birth outcomes. A safety net program focused on covering the costs of rent during pregnancy may aid in preventing adverse complications. OBJECTIVE: This study aimed to evaluate the cost-effectiveness of a program covering the cost of rent to prevent eviction during pregnancy. STUDY DESIGN: A cost-effectiveness model using TreeAge software was designed to evaluate the cost, effectiveness, and incremental cost-effectiveness ratio associated with eviction compared to no eviction during pregnancy. The cost of eviction from a societal perspective was compared to the annual cost of housing in the no eviction group, which was estimated by the median contract rent in the United States from 2021 national census data. Birth outcomes included preterm birth, neonatal death, and major neurodevelopmental delay. Probabilities and costs were derived from the literature. The cost-effectiveness threshold was set at $100,000/QALY. We performed univariable and multivariable sensitivity analyses to assess the robustness of the results. RESULTS: In our theoretical cohort of 30,000 pregnant individuals aged 15 to 44 years facing eviction annually, the no eviction during pregnancy strategy was associated with 1427 fewer preterm births, 47 fewer neonatal deaths, and 44 fewer cases of neurodevelopmental delay compared to eviction. At the median cost of rent in the United States, the no eviction strategy was associated with increased quality-adjusted life-years and decreased costs. Therefore, the no eviction strategy was the dominant strategy. In univariate sensitivity analysis varying the cost of housing, no eviction remained the cost-effective strategy and was cost-saving when rent was below $1016 per month. CONCLUSION: The no eviction strategy is cost-effective and reduces cases of preterm birth, neonatal death, and neurodevelopmental delay. When rent is below the median of $1016 per month, no eviction is the cost-saving strategy. These findings suggest that policies supporting social programmatic implementation for rent coverage for pregnant people at risk of eviction have the potential to be highly beneficial in reducing costs and disparities in perinatal outcomes.

Universal Tetanus-Diphtheria-Pertussis Vaccination During Pregnancy: A Cost-Effectiveness Analysis.

OBJECTIVE: To assess the cost effectiveness of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccination in pregnant patients in the United States. METHODS: A decision-analytic model in TreeAge was developed to compare universal Tdap vaccination in pregnancy with no Tdap vaccination in pregnancy using a theoretical cohort of 3.66 million pregnant individuals, the approximate number of deliveries per year in the United States. Outcomes included infant pertussis infections, infant hospitalizations, infant encephalopathy cases, infant deaths, and maternal pertussis infections. All probabilities and costs were derived from the literature. Utilities were applied to discounted life expectancies at a rate of 3% to generate quality-adjusted life-years (QALYs). A strategy was considered cost effective if it had an incremental cost-effectiveness ratio of less than $100,000 per QALY. Univariable and multivariable sensitivity analyses were performed to assess the robustness of the model to changes in the baseline assumptions. RESULTS: With a baseline assumption of vaccine cost at $47.75, Tdap vaccination was cost effective at $7,601 per QALY. The vaccination strategy was associated with a decrease of 22 infant deaths, 11 infant encephalopathy cases, 2,018 infant hospitalizations, 6,164 infant pertussis infections, and 8,585 maternal pertussis infections, with an increase of 19,489 QALYs. In sensitivity analyses, the strategy was cost effective until the incidence of maternal pertussis became lower than 1.6 cases per 10,000 individuals, the cost of the Tdap vaccine was greater than $540, or previous pertussis immunity was present in more than 92.1% of pregnant individuals. CONCLUSION: In a theoretical U.S. cohort of 3.66 million pregnant individuals, Tdap vaccination during pregnancy is cost effective and reduces infant morbidity and mortality compared with no vaccination during pregnancy. These findings are especially relevant given that approximately half of individuals are not vaccinated during pregnancy and recent data have shown that postpartum maternal vaccination and cocooning strategies are ineffective. Public health strategies to encourage greater uptake of Tdap vaccination should be used to reduce the morbidity and mortality of pertussis infection.

Adjuvant Human Papillomavirus Vaccination After Excisional Procedure for Cervical Intraepithelial Neoplasia: A Cost-Effectiveness Analysis.

OBJECTIVE: To examine the cost effectiveness of human papillomavirus (HPV) vaccination after excisional procedure compared with no vaccination. METHODS: We constructed a decision-analytic model (TreeAge Pro 2021) to compare outcomes between patients who underwent an excisional procedure followed by nonavalent HPV vaccination to those who underwent an excisional procedure without vaccination. Our theoretical cohort contained 250,000 patients, the approximate number undergoing excisional procedures annually in the United States. Our outcomes were costs, quality-adjusted life-years (QALYs), recurrence events, number of surveillance Pap tests with co-testing, number of colposcopies, and second excisional procedures. Probabilities of recurrence were based on a recently published meta-analysis. All values were derived from the literature, and QALYs were discounted at a rate of 3%. Outcomes were applied for 4 years after the initial excisional procedure. Our cost-effectiveness threshold was $100,000 per QALY. Sensitivity analyses were performed to evaluate the robustness of the model. RESULTS: In our theoretical cohort of patients who underwent an excisional procedure, the HPV vaccination strategy was associated with 17,281 fewer recurrences of cervical intraepithelial neoplasia (CIN) (8,360 fewer cases of CIN 1 and 8,921 fewer cases of CIN 2 or 3), 26,203 fewer Pap tests (1,025,368 vs 1,051,570), 17,281 fewer colposcopies (20,588 vs 37,869), and 8,921 fewer second excisional procedures (4,779 vs 13,701). The vaccination strategy was associated with a higher cost of $135 million. Vaccination was a cost-effective strategy, with an incremental cost-effectiveness ratio of $29,181 per QALY, compared with no vaccination. In our sensitivity analyses, the HPV vaccination strategy remained cost effective until the cost of the three-dose HPV vaccine series reached $1,899 or the baseline (nonvaccinated) probability of recurrence was less than 4.8%. CONCLUSION: In our model, HPV vaccination for patients with a prior excisional procedure led to improved outcomes and was cost effective. Our study suggests that clinicians should consider offering the three-dose HPV vaccine series to patients who have undergone an excisional procedure to decrease the risk of CIN recurrence and its sequelae.

Association Between Rates of Down Syndrome Diagnosis in States With vs Without 20-Week Abortion Bans From 2011 to 2018.

Importance: Many states enacted 20-week abortion bans from 2011 to 2018. Such bans affect individuals who receive diagnoses of fetal anomalies and aneuploidy in the second trimester, preventing pregnant individuals from having the choice of whether or not to continue the pregnancy. Objectives: To examine the trends of neonatal Down syndrome rates and assess the association between enactment of 20-week abortion bans and rates of Down syndrome diagnosis. Design, Setting, and Participants: This population-based, historical cohort study used National Vital Statistics System data on 31 157 506 births in the US from 2011 to 2018. Statistical analysis was performed from May 2021 to February 2023. Exposure: States were categorized as those with or without a 20-week abortion ban enacted during the study period. Main Outcomes and Measures: Demographic characteristics between the ban and no-ban states were compared using χ2 tests and 2-sample t tests. Multivariable logistic regression evaluated the adjusted odds of Down syndrome among births in states that enacted 20-week abortion bans after the abortion ban enactment, adjusting for state, year of birth, maternal race and ethnicity, age, educational level, insurance, and number of prenatal visits. Results: The cohort consisted of 31 157 506 births (mean [SD] maternal age, 28.4 [5.9] years) in the United States, of whom 15 951 neonates (0.05%) received a diagnosis of Down syndrome at birth. A total of 17 states enacted 20-week abortion bans during the study period, and 33 states did not enact bans. In both states with and states without bans, the birth prevalence of neonatal Down syndrome increased over time; in states with bans, rates increased from 48.0 to 58.4 per 100 000 births; in states without bans, rates increased from 47.4 to 53.3 per 100 000 births. In multivariable logistic regression assessing the interaction of time and presence of a 20-week abortion ban, the odds of Down syndrome were higher in states that enacted 20-week abortion bans after enactment of the law compared with the years prior to enactment of the ban (adjusted odds ratio, 1.22; 95% CI, 1.11-1.35). Conclusions and Relevance: In the US from 2011 to 2018, neonatal Down syndrome diagnoses increased more in states that enacted 20-week abortion bans compared with states that did not enact bans. Because these abortion bans were enacted throughout the study period and are known to inhibit choice in patient decision-making, it is possible that the difference in the rates of diagnosis is associated with these policies.

Universal Repeat Screening for Human Immunodeficiency Virus in the Third Trimester of Pregnancy: A Cost-Effectiveness Analysis.

OBJECTIVE: To assess the cost effectiveness of universal repeat screening for human immunodeficiency virus (HIV) infection in the third trimester of pregnancy. METHODS: A decision-analytic model was constructed to compare two strategies: screening for HIV infection in the first trimester alone compared with the addition of repeat screening in the third trimester. Probabilities, costs, and utilities were derived from the literature and varied in sensitivity analyses. The assumed incidence of HIV infection in pregnancy was 0.0145% or 14.5 per 100,000. Outcomes included costs (in 2022 U.S. dollars), maternal and neonatal quality-adjusted life-years (QALYs), and cases of neonatal HIV infection. Our theoretical cohort contained 3.8 million pregnant individuals, the approximate number of births per year in the United States. The willingness-to-pay threshold was set at $100,000/QALY. We performed univariable and multivariable sensitivity analyses to determine inputs that most influenced the model. RESULTS: Universal third-trimester screening prevented 133 cases of neonatal HIV infection in this theoretical cohort. Universal third-trimester screening led to an increased cost of $17.54 million and 2,732 increased QALYs, with an incremental cost-effectiveness ratio of $6,418.56 per QALY, less than the willingness-to-pay threshold. In a univariate sensitivity analysis, third-trimester screening remained cost effective with variation of HIV incidence in pregnancy to as low as 0.0052%. CONCLUSION: In a theoretical U.S.-based cohort of pregnant individuals, universal repeat screening for HIV infection in the third trimester was found to be cost effective and to reduce vertical transmission of HIV. These results merit consideration of a broader HIV-screening program in the third trimester.

Hysterectomy with a general gynecologist vs gynecologic-oncologist in the setting of endometrial intraepithelial neoplasia: a cost-effectiveness analysis.

BACKGROUND: Standard treatment for patients with endometrial intraepithelial neoplasia (EIN) is a hysterectomy, which has a 43% risk of concomitant endometrial cancer on final pathology. General gynecologists and gynecologic-oncologists perform hysterectomies; however, patients who have a hysterectomy for EIN with a general gynecologist and are found to have cancer may require a second surgery by a gynecologic-oncologist to complete staging. There is ongoing discussion regarding whether patients with EIN should be provided the option to receive the initial hysterectomy with a gynecologic-oncologist. OBJECTIVE: This study aimed to better understand if patients with EIN should be initially referred to a gynecologic-oncologist for treatment. We examined the cost-effectiveness of hysterectomy by general gynecologists vs gynecologic-oncologists for patients with EIN. STUDY DESIGN: We created a decision-analytical model using TreeAge Pro software to compare outcomes between hysterectomies by general gynecologists and those by gynecologic-oncologists in patients with EIN. Our theoretical cohort contained 200,000 patients, an estimate of the number of individuals diagnosed with EIN each year in the United States. Outcomes included costs, quality-adjusted life years, primary lymph node dissection, secondary lymph node dissection, surgical site infection, and perioperative mortality. We assumed that surgical morbidity and mortality were the same under generalist and specialist care and applied costs of travel and lost work for those seeing a gynecologic-oncologist. We performed univariable sensitivity analyses and multivariable probabilistic sensitivity analysis to assess the model's robustness given the uncertainty of model inputs. RESULTS: In our theoretical cohort of 200,000 patients with EIN, hysterectomy with a gynecologic-oncologist was associated with a decrease of 10,811 second surgeries for lymph node dissection, 87 surgical site infections, and 9 perioperative mortalities. When hysterectomy was performed by a general gynecologist, 9 fewer patients had a lymph node dissection because of perioperative mortalities that occurred before lymph node dissection with a gynecologic-oncologist. Hysterectomy with a gynecologic-oncologist was the dominant, cost-effective strategy because it saved $116 million and increased quality-adjusted life years by 180. In our univariable analyses, hysterectomy with a gynecologic-oncologist was cost-saving and increased quality-adjusted life years over a wide range of probabilities and costs for lymph node dissection, surgical site infection, and perioperative mortality. However, hysterectomy with a gynecologic-oncologist was only a cost-effective and cost-saving strategy in just over 50% of multivariable simulations, demonstrating that there is significant uncertainty in the model's cost-effectiveness. CONCLUSION: In our model, hysterectomy with a gynecologic-oncologist for patients with EIN was associated with cost savings and increased quality-adjusted life years. Our study supports that patients undergoing hysterectomy for EIN at institutions using Mayo criteria to determine need for lymphadenectomy may benefit from surgery with a gynecologic-oncologist rather than a general gynecologist to reduce costs and adverse events associated with a second surgery.

Cesarean delivery rates by hospital type among nulliparous and multiparous patients.

BACKGROUND: Cesarean delivery rates continue to remain high despite recent attempts to decrease these rates. Prior data suggest that there is great variation in cesarean rates by hospital. OBJECTIVE: The intent of this study is to examine the association of several hospital characteristics and cesarean delivery rates in California. METHODS: We performed a retrospective study of singleton, non-anomalous, term (37-42 week) deliveries in California. We excluded hospitals with <50 deliveries per year and missing hospital information. We separated hospitals by volume based on previously published categories: low-volume (<1200 deliveries/year), medium-volume (1200-2399 deliveries/year), and medium-high-volume (2400-3599 deliveries/year, and high-volume (3600 deliveries/year). We also evaluated rural versus urban and non-teaching versus teaching hospitals. We examined overall cesarean rates as well as stratified by parity and with and without prior cesarean. We analyzed data with chi-square tests and multivariable logistic regression models. RESULTS: In a total of 2,545,464 pregnancies, 772,539 (30.35%) resulted in cesarean deliveries. After controlling for race/ethnicity, age, body mass index, education, and insurance, rates of cesarean delivery were higher in low-volume hospitals (aOR: 1.07; 95% CI: 1.0-1.08) and lower in medium-high-volume hospitals (aOR: 0.97; 95% CI: 0.96-0.98) as compared to high-volume hospitals. Rural hospitals had higher rates of cesarean delivery (aOR: 1.08; 95% CI: 1.06-1.10) as compared to urban hospitals while non-teaching hospitals had higher odds of cesarean deliveries (aOR: 1.27; 95% CI: 1.25-1.28) as compared with teaching hospitals. Among nulliparous patients, medium- and medium-high-volume hospitals had lower rates of cesarean deliveries (aOR: 0.95; 95% CI: 0.93-0.96; aOR: 0.93; 95% CI: 0.91-0.94) as compared to high-volume hospitals, while non-teaching hospitals had higher rates of cesarean deliveries than teaching hospitals (aOR: 1.11; 95% CI: 1.10-1.13). Multiparous patients without prior cesarean had higher rates of cesarean delivery at low-volume hospitals and lower rates of cesarean delivery at medium-high-volumes (aOR: 1.07; 95% CI: 1.05-1.10; aOR: 0.96; 95% CI: 0.94-0.098) as compared to high-volume hospitals. Additionally, multiparous patients without prior cesarean had higher rates of cesarean delivery at non-teaching hospitals than teaching hospitals (aOR: 1.16; 95% CI: 1.13-1.19). Multiparous patients with prior cesarean had high rates of cesarean delivery at all volume hospitals with the highest odds at low-volume hospitals (aOR: 1.81; 95% CI: 1.74, 1.89) as well as at rural and non-teaching hospitals. CONCLUSION: Cesarean delivery rates were higher at low and high-volume hospitals for nulliparous and multiparous patients without prior cesarean, but increased with decreasing hospital volume for multiparous patients with prior cesarean. Additionally, cesarean delivery was more likely at rural and non-teaching hospitals. Our results suggest that further investigation is necessary to determine the structural and mechanistic causes of the differences in practice by hospital type in order to identify targets for approaches in reducing cesarean deliveries.

Cost-effectiveness of influenza vaccination during pregnancy.

OBJECTIVE: To assess the cost-effectiveness of influenza vaccination for all pregnant patients in the United States. METHODS: We designed a cost-effectiveness model to compare outcomes and costs in pregnant patients who received the inactivated, trivalent influenza vaccine to those who did not. We used a theoretical cohort of 4 million patients, the number of individuals giving birth in the United States per year. We assumed that H1N1 and A or B type influenza were of equal incidence based on seasonal variation from the past ten years. Our outcomes include acquiring H1N1, acquiring A or B type influenza, maternal death, stillbirth, infant death, preterm birth, and cerebral palsy in addition to cost and quality-adjusted life years (QALYs). Probabilities were derived from the literature and QALYs generated at a discount rate of 3%. Sensitivity analyses were performed to assess the robustness of our model. RESULTS: In our theoretical cohort of 4 million pregnant patients, the influenza vaccination strategy was associated with 1632 fewer stillbirths (24,332 in the vaccine strategy vs. 25,964 in the no vaccine strategy), 120 fewer maternal deaths (284 vs. 404), 340 fewer infant deaths (5608 vs. 5948), 32,856 fewer preterm births (403,896 vs. 436,752), and 641 fewer cases of moderate cerebral palsy (12,388 vs. 13,029). Additionally, the vaccination strategy corresponded to savings of $3.7 billion ($63.3 billion vs. $67.0 billion) and increased QALYs of 81,696 (226,852,076 vs 226,770,380). Therefore, it was considered a dominant strategy. Univariate sensitivity analysis demonstrated that the vaccine is cost saving until vaccine cost passes $900, far above the current cost of $12.16. In addition, we used sensitivity analysis to vary seasonal proportions of H1N1 to A or B type influenza. The vaccine was cost saving and increased QALYs for any proportion of H1N1 to A or B type influenza including when H1N1 was absent. CONCLUSION: We demonstrate that in a cohort of 4 million patients, the influenza vaccine may save $3.7 billion per year, improve maternal and infant outcomes, and reduce morbidity and mortality. Our study provides further evidence that providers should strongly recommend that pregnant patients receive their annual influenza vaccine.

A cost-effectiveness analysis of universal hepatitis C screening in all United States pregnancies.

OBJECTIVE: To evaluate the cost-effectiveness of universal screening for HCV among all pregnant women in the United States. METHODS: We designed a decision-analytic model to evaluate the cost-effectiveness and outcomes associated with universal HCV screening in pregnancy compared to no screening. A theoretical cohort of 3.9 million women, the approximate number of annual live births in the United States was used. Outcomes included hepatocellular carcinoma, decompensated cirrhosis, liver transplant and death, in addition to cost and quality-adjusted life years (QALYs). Model inputs were derived from the literature and the willingness-to-pay threshold was $100,000 per QALY. Sensitivity analysis were conducted to evaluate the robustness of the results. RESULTS: In a theoretical cohort of 3.9 million women, universal HCV screening resulted in 3003 fewer cases of hepatocellular carcinoma, 1484 fewer decompensated cirrhosis, 46 fewer liver transplants and 2665 fewer deaths from HCV when compared to no screening. Universal HCV screening was found to be the dominant strategy, meaning it resulted in lower costs and higher QALYs. Sensitivity analyses showed our model was robust over a wide range of assumptions. CONCLUSION: Among pregnant women in the United States, universal HCV screening is cost effective compared with no screening.

Factors Associated With Perceived Trust of False Abortion Websites: Cross-sectional Online Survey.

BACKGROUND: Most patients use the internet to search for health information. While there is a vast repository of searchable information online, much of the content is unregulated and therefore potentially incorrect, conflicting, or confusing. Abortion information online is particularly prone to being inaccurate as antichoice websites publish purposefully misleading information in formats that appear as neutral resources. To understand how antichoice websites appear neutral, we need to understand the specific website features of antichoice websites that impart an impression of trustworthiness. OBJECTIVE: We sought to identify the characteristics of false or misleading abortion websites that make these websites appear trustworthy to the public. METHODS: We conducted a cross-sectional study using Amazon's Mechanical Turk platform. We used validated questionnaires to ask participants to rate 11 antichoice websites and one neutral website identified by experts, focusing on website content, creators, and design. We collected sociodemographic data and participant views on abortion. We used a composite measure of "mean overall trust" as our primary outcome. Using correlation matrices, we determined which website characteristics were most associated with mean overall trust. Finally, we used linear regression to identify participant characteristics associated with overall trust. RESULTS: Our analytic sample included 498 participants aged from 22 to 70 years, and 50.1% (247/493) identified as female. Across 11 antichoice websites, creator confidence ("I believe that the creators of this website are honest and trustworthy") had the highest correlation coefficient (strongest relationship) with mean overall trust (coefficient=0.70). Professional appearance (coefficient=0.59), look and feel (coefficient=0.59), perception that the information is created by experts (coefficient=0.59), association with a trustworthy organization (coefficient=0.58), valued features and functionalities (coefficient=0.54), and interactive capabilities (coefficient=0.52) all demonstrated strong relationships with mean overall trust. At the individual level, prochoice leaning was associated with higher overall trust of the neutral website (B=-0.43, 95% CI -0.87 to 0.01) and lower mean overall trust of the antichoice websites (B=0.52, 95% CI 0.05 to 0.99). CONCLUSIONS: The mean overall trust of antichoice websites is most associated with design characteristics and perceived trustworthiness of website creators. Those who believe that access to abortion should be limited are more likely to have higher mean overall trust for antichoice websites.

A qualitative study of digoxin injection before dilation and evacuation.

OBJECTIVE: We sought to qualitatively understand patients' experiences with digoxin as a step before dilation and evacuation (D&E). STUDY DESIGN: We recruited English-speaking women from one abortion health center where digoxin is routinely used before D&E. We interviewed participants one to three weeks after the D&E about physical and emotional experiences with digoxin and understanding of its purpose. Using grounded theory, we analyzed transcripts iteratively, identifying themes from interviews; we stopped recruitment when we reached thematic saturation. RESULTS: We conducted 20 interviews and participants described mixed experiences. Three overarching themes from the qualitative interviews were: (1) physical and emotional discomfort; (2) varied understanding of digoxin's purpose and effects; and (3) reassurance. Most participants described significantly negative experiences with digoxin; however, many participants also described positive aspects of the injection intermingled with those negative experiences. CONCLUSIONS: Participants' experiences with digoxin before D&E were both polarized and nuanced. While participants were largely clear about digoxin's action, they were much less clear about the reason for its use. IMPLICATIONS: Both the clinical purpose for and patients' experiences with digoxin before D&E are complicated. Providers who continue to use digoxin should consider patient preferences in how they offer digoxin, and consider tools to ensure patient understanding.