State variations in insertion of long-acting reversible contraception during delivery hospitalization.

OBJECTIVES: This study aimed to describe immediate postpartum long-acting reversible contraception (IPP LARC) insertion rates during delivery hospitalizations at the state level and by payor type. STUDY DESIGN: This is a cross-sectional study of 26 states and District of Columbia using 2020 State Inpatient Database. RESULTS: In 2020, IPP LARC insertion rates varied widely by states, ranging from 2.55 to 637.25 per 10,000 deliveries. Rates were higher for deliveries with Medicaid as primary expected payor than with private insurance in all states but District of Columbia. CONCLUSIONS: Rates of IPP LARC insertion varied in 2020 by state and were higher for deliveries with Medicaid as primary expected payor.

Continuation of Reversible Contraception Following Enrollment in the Zika Contraception Access Network (Z-CAN) in Puerto Rico, 2016-2020.

The Zika Contraception Access Network (Z-CAN) provided access to high-quality client-centered contraceptive services across Puerto Rico during the 2016-2017 Zika virus outbreak. We sent online surveys during May 2017-August 2020 to a subset of Z-CAN patients at 6, 24, and 36 months after program enrollment (response rates: 55-60 percent). We described contraceptive method continuation, method satisfaction, and method switching, and we identified characteristics associated with discontinuation using multivariable logistic regression. Across all contraceptive methods, continuation was 82.5 percent, 64.2 percent, and 49.9 percent at 6, 24, and 36 months, respectively. Among continuing users, method satisfaction was approximately ≥90 percent. Characteristics associated with decreased likelihood of discontinuation included: using an intrauterine device or implant compared with a nonlong-acting reversible contraceptive method (shot, pills, ring, patch, or condoms alone); wanting to prevent pregnancy at follow-up; and receiving as their baseline method the same method primarily used before Z-CAN. Other associated characteristics included: receiving the method they were most interested in postcounseling (6 and 24 months) and being very satisfied with Z-CAN services at the initial visit (6 months). Among those wanting to prevent pregnancy at follow-up, about half reported switching to another method. Ongoing access to contraceptive services is essential for promoting reproductive autonomy, including supporting patients with continued use, method switching, or discontinuation.

Claims for Contraceptive Services and Chlamydia and Gonorrhea Testing Among Insured Adolescent and Young Adult Females in the United States.

Objective: To examine claims for reversible prescription contraceptives and chlamydia and gonorrhea testing among commercially and Medicaid-insured adolescent and young adult (AYA) females in the United States. Methods: Using IBM MarketScan Research Databases, we identified sexually active, nonpregnant AYA (15- to 24-year-old) females enrolled in 2018. We examined claims for reversible prescription contraceptives and chlamydia and gonorrhea testing, using drug names and diagnosis/procedure codes, by age-group in commercially and Medicaid-insured separately and by race/ethnicity in Medicaid-insured. Results: Among 15- to 19-year-old and 20- to 24-year-old females, 67.2% and 67.9% of commercially insured and 57.3% and 54.0% of Medicaid-insured, respectively, had claims for reversible prescription contraceptives in 2018. Across insurance types among both age-groups, the most common claim for contraceptives was prescription for combined oral contraceptives. Among Medicaid-insured 15- to 19-year-olds, claims for contraceptives ranged from 42.6% for Hispanic females to 63.4% for non-Hispanic White females; among Medicaid-insured 20- to 24-year-olds, claims ranged from 50.4% for non-Hispanic Black females to 57.0% for non-Hispanic White females. Approximately half of the commercially and Medicaid-insured females had claims for chlamydia and gonorrhea testing. Non-Hispanic Black females had the highest percentages of claims for chlamydia testing (56.3% among 15- to 19-year-olds and 61.1% among 20- to 24-year-olds) and gonorrhea testing (61.6% among 15- to 19-year-olds and 64.9% among 20- to 24-year-olds). Conclusion: Approximately, two-thirds of commercially insured and more than half of Medicaid-insured, sexually active, nonpregnant AYA females had claims for reversible prescription contraceptives. Race/ethnicity data were available for Medicaid-insured females, and there were differences in claims for contraceptives and chlamydia and gonorrhea testing by race/ethnicity. Half of the AYA females had claims for chlamydia and gonorrhea testing suggesting missed opportunities.

Long-acting reversible contraception use and unmet desire among patients after the Zika Contraception Access Network Program in Puerto Rico.

OBJECTIVES: To describe unmet desire for long-acting reversible contraception (LARC) after the Zika Contraception Access Network (Z-CAN) in Puerto Rico during the 2016-2017 Zika outbreak. STUDY DESIGN: Z-CAN patients completed surveys about contraception experiences over a 3-year period. RESULTS: Of 1809 respondents, 3% never used LARC but reported wanting it since their initial visit. As reasons for not getting LARC, nearly 50% indicated a provider-related reason and 25% reported cost. CONCLUSIONS: Few Z-CAN patients who never used LARC had unmet desire. Provider training in contraception guidelines and strategies to address costs can expand access to the full range of reversible contraception. IMPLICATIONS: Three years after a short-term program provided reversible contraception in Puerto Rico, few respondents had never used but wanted a long-acting reversible contraception method. Nearly half reported provider-related reasons for not receiving long-acting reversible contraception, and 25% reported cost. Provider awareness of contraceptive guidance and method availability can support client-centered care.

Changes in Commercial Insurance Claims for Contraceptive Services During the Beginning of the COVID-19 Pandemic-United States, January 2019-September 2020.

OBJECTIVE: We describe changes in commercial insurance claims for contraceptive services during the beginning of the COVID-19 pandemic. METHODS: We analyzed commercial insurance claims using IQVIA PharMetrics Plus data from more than 9 million U.S. females aged 15-49 years, enrolled during any month, January 2019 through September 2020. We calculated monthly rates of outpatient claims for intrauterine devices (IUDs), implants, and injectable contraception and monthly rates of pharmacy claims for contraceptive pills, patches, and rings. We used Joinpoint regression analysis to identify when statistically significant changes occurred in trends of monthly claims rates for each contraceptive method. We calculated monthly percentages of claims for contraceptive counseling via telehealth. RESULTS: Monthly claims rates decreased for IUDs (-50%) and implants (-43%) comparing February 2020 with April 2020 but rebounded by June 2020. Monthly claims rates for injectables decreased (-19%) comparing January 2019 with September 2020, and monthly claims rates for pills, patches, and rings decreased (-22%) comparing July 2019 with September 2020. The percentage of claims for contraceptive counseling occurring via telehealth was low (<1%) in 2019, increased to 34% in April 2020, and decreased to 9-12% in June-September 2020. CONCLUSIONS: Substantial changes in commercial insurance claims for contraceptive services occurred during the beginning of the COVID-19 pandemic, including transient decreases in IUD and implant claims and increases in telehealth contraceptive counseling claims. Contraceptive claims data can be used by decision makers to identify service gaps and evaluate use of interventions like telehealth to improve contraceptive access, including during public health emergencies.

Breastfeeding by Disability Status in the United States: Pregnancy Risk Assessment Monitoring System, 2018-2020.

Objectives. To describe breastfeeding initiation and breastfeeding at 1, 2, and 3 months, and information sources on breastfeeding among women with a recent live birth by disability status. Methods. We analyzed October 2018 to December 2020 data from the Pregnancy Risk Assessment Monitoring System for 24 sites in the United States that included the Washington Group Short Set of Questions on Disability (seeing, hearing, walking or climbing stairs, remembering or concentrating, self-care, communicating). We defined disability as reporting "a lot of difficulty" or "cannot do this at all" on any of these questions. Results. Among 39 673 respondents, 6.0% reported disability. In adjusted analyses, breastfeeding was lower among respondents with disability at 2 (62.6% vs 66.6%; adjusted prevalence ratio [APR] = 0.94; 95% confidence interval [CI] = 0.89, 0.99) and 3 months (54.7% vs 59.6%; APR = 0.92; 95% CI = 0.86, 0.98) than those without disability. Respondents with disability were less likely to receive information from health care providers or support professionals (89.3% vs 92.3%), but as likely from breastfeeding or lactation specialists (78.1% vs 75.3%). Conclusions. Strategies to ensure women with disability, receive breastfeeding support, including breastfeeding information, could improve breastfeeding outcomes. (Am J Public Health. 2024;114(1):108-117. https://doi.org/10.2105/AJPH.2023.307438).

Abortion Surveillance - United States, 2021.

Problem/Condition: CDC conducts abortion surveillance to document the number and characteristics of women obtaining legal induced abortions and number of abortion-related deaths in the United States. Period Covered: 2021. Description of System: Each year, CDC requests abortion data from the central health agencies for the 50 states, the District of Columbia, and New York City. For 2021, a total of 48 reporting areas voluntarily provided aggregate abortion data to CDC. Of these, 47 reporting areas provided data each year during 2012-2021. Census and natality data were used to calculate abortion rates (number of abortions per 1,000 women aged 15-44 years) and ratios (number of abortions per 1,000 live births), respectively. Abortion-related deaths from 2020 were assessed as part of CDC's Pregnancy Mortality Surveillance System (PMSS). Results: A total of 625,978 abortions for 2021 were reported to CDC from 48 reporting areas. Among 47 reporting areas with data each year during 2012-2021, in 2021, a total of 622,108 abortions were reported, the abortion rate was 11.6 abortions per 1,000 women aged 15-44 years, and the abortion ratio was 204 abortions per 1,000 live births. From 2020 to 2021, the total number of abortions increased 5% (from 592,939 total abortions), the abortion rate increased 5% (from 11.1 abortions per 1,000 women aged 15-44 years), and the abortion ratio increased 4% (from 197 abortions per 1,000 live births). From 2012 to 2021, the total number of reported abortions decreased 8% (from 673,634), the abortion rate decreased 11% (from 13.1 abortions per 1,000 women aged 15-44 years), and the abortion ratio decreased 1% (from 207 abortions per 1,000 live births).In 2021, women in their 20s accounted for more than half of abortions (57.0%). Women aged 20-24 and 25-29 years accounted for the highest percentages of abortions (28.3% and 28.7%, respectively) and had the highest abortion rates (19.7 and 19.4 abortions per 1,000 women aged 20-24 and 25-29 years, respectively). By contrast, adolescents aged <15 years and women aged ≥40 years accounted for the lowest percentages of abortions (0.2% and 3.6%, respectively) and had the lowest abortion rates (0.4 and 2.5 abortions per 1,000 women aged <15 and ≥40 years, respectively). However, abortion ratios were highest among adolescents (aged ≤19 years) and lowest among women aged 30-39 years.From 2020 to 2021, abortion rates increased among women aged 20-39 years, decreased among adolescents aged 15-19 years, and did not change among adolescents aged <15 years and women aged ≥40 years. Abortion rates decreased from 2012 to 2021 among all age groups, except women aged 30-34 years for whom it increased. The decrease in the abortion rate from 2012 to 2021 was highest among adolescents compared with any other age group. From 2020 to 2021, abortion ratios increased for women aged 15-24 years, decreased among adolescents aged <15 years and women aged ≥35 years and did not change for women aged 25-34 years. From 2012 to 2021, abortion ratios increased among women aged 15-29 years and decreased among adolescents aged <15 years and women aged ≥30 years. The decrease in abortion ratio from 2012 to 2021 was highest among women aged ≥40 years compared with any other age group.In 2021, the majority (80.8%) of abortions were performed at ≤9 weeks' gestation, and nearly all (93.5%) were performed at ≤13 weeks' gestation. During 2012-2021, the percentage of abortions performed at >13 weeks' gestation remained ≤8.7%. In 2021, the highest percentage of abortions were performed by early medication abortion at ≤9 weeks' gestation (53.0%), followed by surgical abortion at ≤13 weeks' gestation (37.6%), surgical abortion at >13 weeks' gestation (6.4%), and medication abortion at >9 weeks' gestation (3.0%); all other methods were uncommon (<0.1%). Among those that were eligible (≤9 weeks' gestation), 66.6% of abortions were early medication abortions. In 2020, the most recent year for which PMSS data were reviewed for pregnancy-related deaths; six women died as a result of complications from legal induced abortion. Interpretation: Among the 47 areas that reported data continuously during 2012-2021, overall decreases were observed during 2012-2021 in the total number, rate, and ratio of reported abortions; however, from 2020 to 2021, increases were observed across all measures. Public Health Action: Abortion surveillance can be used to help evaluate programs aimed at promoting equitable access to patient-centered quality contraceptive services in the United States to reduce unintended pregnancies.

Is the COVID-19 Pandemic Continuing to Impact Sexual and Reproductive Health Services for Adolescents? Findings From a 2021 Survey of US Physicians.

PURPOSE: We examined the impact of the COVID-19 pandemic in Fall 2021 on sexual and reproductive health (SRH) services among physicians whose practice provided these services to adolescents just before the pandemic. METHODS: Data were from the DocStyles online panel survey administered September-November 2021 to US physicians who reported their practice provided SRH services to adolescent patients before the pandemic (n = 948). We calculated prevalence of service delivery challenges (e.g., limited long-acting reversible contraception services) and use of strategies to support access (e.g., telehealth) in the month prior to survey completion, compared these estimates with prevalence "at any point during the COVID-19 pandemic", and examined differences by physician specialty and adolescent patient volume. RESULTS: Fewer physicians reported their practice experienced service delivery challenges in the month prior to survey completion than at any point during the pandemic. About 10% indicated limited long-acting reversible contraception and sexually transmitted infection testing services in the prior month overall; prevalence varied by physician specialty (e.g., 26% and 17%, respectively by service, among internists). Overall, about 25% of physicians reported reductions in walk-in hours, weekend/evening hours, and adolescents seeking care in the prior month. While most practices that initiated strategies supporting access to services during the pandemic used such strategies in the prior month, some practices (22%-37% depending on the strategy) did not. DISCUSSION: Findings suggest some physicians who serve adolescents continued to experience challenges providing SRH services in the Fall 2021, and some discontinued strategies to support access that had been initiated during the pandemic.

Contraception claims by medication for opioid use disorder prescription status among insured women with opioid use disorder, United States, 2018.

OBJECTIVE(S): To understand how contraception method use differed between women prescribed and not prescribed medications for opioid use disorder (MOUD) among commercially-insured and Medicaid-insured women. STUDY DESIGN: IBM Watson Health MarketScan Commercial Claims and Encounters database and the Multi-State Medicaid database were used to calculate the (1) crude prevalence, and (2) adjusted odds ratios (adjusted for demographic characteristics) of using long-acting reversible or short-acting hormonal contraception methods or female sterilization compared with none of these methods (no method) in 2018 by MOUD status among women with OUD, aged 20 to 49 years, with continuous health insurance coverage through commercial insurance or Medicaid for ≥6 years. Claims data was used to define contraception use. Fisher exact test or χ2 test with a P-value ≤ 0.0001, based on the Holm-Bonferroni method, and 95% confidence intervals were used to determine statistically significant differences for prevalence estimates and adjusted odds ratios, respectively. RESULTS: Only 41% of commercially-insured and Medicaid-insured women with OUD were prescribed MOUD. Medicaid-insured women with OUD prescribed MOUD had a significantly lower crude prevalence of using no method (71.1% vs 79.0%) and higher odds of using female sterilization (aOR, 1.33; 95% CI: 1.06-1.67 vs no method) than those not prescribed MOUD. Among commercially-insured women there were no differences in contraceptive use by MOUD status and 66% used no method. CONCLUSIONS: Among women with ≥ 6 years of continuous insurance coverage, contraceptive use differed by MOUD status and insurance. Prescribing MOUD for women with OUD can be improved to ensure quality care. IMPLICATIONS: Only two in five women with OUD had evidence of being prescribed MOUD, and majority did not use prescription contraception or female sterilization. Our findings support opportunities to improve prescribing for MOUD and integrate contraception and MOUD services to improve clinical care among women with OUD.

Intrauterine Device Training, Attitudes, and Practices Among U.S. Health Care Providers: Findings from a Nationwide Survey.

BACKGROUND: Provider training in intrauterine device (IUD) procedures is a key strategy for improving evidence-based IUD care. We examined the influence of IUD training on IUD attitudes and practices among U.S. family planning providers. METHODS: In 2019, we conducted a cross-sectional survey of U.S. family planning providers. We performed logistic regression to examine associations between training in routine IUD placement and specific IUD safety attitudes, confidence performing IUD procedures, and specific IUD practices. RESULTS: Among 1,063 physicians and advanced practice clinicians, 85.1% reported training in routine IUD placement. Overall, IUD training was associated with accurately stating IUDs are safe for queried groups, including patients immediately postpartum (prevalence ratio [PR] 4.22; 95% confidence interval [CI] 1.29-13.85). Trained providers reported higher confidence in routine IUD placement for parous (PR 7.71; 95% CI 1.31-45.3) and nulliparous (PR 7.12; 95% CI 1.17-43.5) women and in IUD removal (PR 2.06; 95% CI 1.12-3.81). Among providers with IUDs available onsite, IUD training was associated with frequent same-day IUD provision for adults (PR 7.32; 95% CI 2.16-24.79) and adolescents (PR 7.63; 95% CI 2.22-26.24). Trained providers were also less likely to routinely use misoprostol before IUD placement for nulliparous (PR 0.19; 95% CI 0.11-0.33) and parous women (PR 0.07; 95% CI 0.03-0.16). CONCLUSION: Training in routine IUD placement was associated with evidence-based IUD safety attitudes, confidence in performing IUD procedures, and clinical practices aligned with Centers for Disease Control and Prevention contraception guidance. Expanding IUD training might increase evidence-based care and patient access to the full range of contraception, including IUDs.

Abortion Surveillance - United States, 2020.

Problem/Condition: CDC conducts abortion surveillance to document the number and characteristics of women obtaining legal induced abortions and number of abortion-related deaths in the United States. Period Covered: 2020. Description of System: Each year, CDC requests abortion data from the central health agencies for the 50 states, the District of Columbia, and New York City. For 2020, a total of 49 reporting areas voluntarily provided aggregate abortion data to CDC. Of these, 48 reporting areas provided data each year during 2011-2020. Census and natality data were used to calculate abortion rates (number of abortions per 1,000 women aged 15-44 years) and ratios (number of abortions per 1,000 live births), respectively. Abortion-related deaths from 2019 were assessed as part of CDC's Pregnancy Mortality Surveillance System (PMSS). Results: A total of 620,327 abortions for 2020 were reported to CDC from 49 reporting areas. Among 48 reporting areas with data each year during 2011-2020, in 2020, a total of 615,911 abortions were reported, the abortion rate was 11.2 abortions per 1,000 women aged 15-44 years, and the abortion ratio was 198 abortions per 1,000 live births. From 2019 to 2020, the total number of abortions decreased 2% (from 625,346 total abortions), the abortion rate decreased 2% (from 11.4 abortions per 1,000 women aged 15-44 years), and the abortion ratio increased 2% (from 195 abortions per 1,000 live births). From 2011 to 2020, the total number of reported abortions decreased 15% (from 727,554), the abortion rate decreased 18% (from 13.7 abortions per 1,000 women aged 15-44 years), and the abortion ratio decreased 9% (from 217 abortions per 1,000 live births).In 2020, women in their 20s accounted for more than half of abortions (57.2%). Women aged 20-24 and 25-29 years accounted for the highest percentages of abortions (27.9% and 29.3%, respectively) and had the highest abortion rates (19.2 and 19.0 abortions per 1,000 women aged 20-24 and 25-29 years, respectively). By contrast, adolescents aged <15 years and women aged ≥40 years accounted for the lowest percentages of abortions (0.2% and 3.7%, respectively) and had the lowest abortion rates (0.4 and 2.6 abortions per 1,000 women aged <15 and ≥40 years, respectively). However, abortion ratios were highest among adolescents (aged ≤19 years) and lowest among women aged 25-39 years.Abortion rates decreased from 2011 to 2020 among all age groups. The decrease in abortion rate was highest among adolescents compared with any other age group. From 2019 to 2020, abortion rates decreased or did not change for all age groups. Abortion ratios decreased from 2011 to 2020 for all age groups, except adolescents aged 15-19 years and women aged 25-29 years for whom abortion ratios increased. The decrease in abortion ratio was highest among women aged ≥40 years compared with any other age group. From 2019 to 2020, abortion ratios decreased for adolescents aged <15 years and women aged ≥35 and increased for women 15-34 years.In 2020, 80.9% of abortions were performed at ≤9 weeks' gestation, and nearly all (93.1%) were performed at ≤13 weeks' gestation. During 2011-2020, the percentage of abortions performed at >13 weeks' gestation remained consistently low (≤9.2%). In 2020, the highest percentage of abortions were performed by early medical abortion at ≤9 weeks' gestation (51.0%), followed by surgical abortion at ≤13 weeks' gestation (40.0%), surgical abortion at >13 weeks' gestation (6.7%), and medical abortion at >9 weeks' gestation (2.4%); all other methods were uncommon (<0.1%). Among those that were eligible (≤9 weeks' gestation), 63.9% of abortions were early medical abortions. In 2019, the most recent year for which PMSS data were reviewed for pregnancy-related deaths, four women died as a result of complications from legal induced abortion. Interpretation: Among the 48 areas that reported data continuously during 2011-2020, overall decreases were observed during 2011-2020 in the total number, rate, and ratio of reported abortions. From 2019 to 2020, decreases also were observed in the total number and rate of reported abortions; however, a 2% increase was observed in the total abortion ratio. Public Health Action: Abortion surveillance can be used to help evaluate programs aimed at promoting equitable access to patient-centered quality contraceptive services in the United States to reduce unintended pregnancies.

Participation in survey research among mothers with a recent live birth: A comparison of mothers with living versus deceased infants - Findings from the Pregnancy Risk Assessment Monitoring System, 2016-2019.

BACKGROUND: Despite high infant mortality rates in the United States relative to other developed countries, little is known about survey participation among mothers of deceased infants. OBJECTIVE: To assess differences in survey response, contact and cooperation rates for mothers of deceased versus. living infants at the time of survey mailing (approximately 2-6 months postpartum), overall and by select maternal and infant characteristics. METHODS: We analysed 2016-2019 data for 50 sites from the Pregnancy Risk Assessment Monitoring System (PRAMS), a site-specific, population-based surveillance system of mothers with a recent live birth. We assessed differences in survey participation between mothers of deceased and living infants. Using American Association for Public Opinion Research (AAPOR) standard definitions and terminology, we calculated proportions of mothers who participated and were successfully contacted among sampled mothers (weighted response and contact rates, respectively), and who participated among contacted mothers (weighted cooperation rate). We then constructed multivariable survey-weighted logistic regression models to examine the adjusted association between infant vital status and weighted response, contact and cooperation rates, within strata of maternal and infant characteristics. RESULTS: Among sampled mothers, 0.3% (weighted percentage, n = 2795) of infants had records indicating they were deceased at the time of survey mailing and 99.7% (weighted percentage, n = 344,379) did not. Mothers of deceased infants had lower unadjusted weighted response (48.3% vs. 56.2%), contact (67.9% vs. 74.3%) and cooperation rates (71.1% vs. 75.6%). However, after adjusting for covariates, differences in survey participation by infant vital status were reduced. CONCLUSIONS: After covariate adjustment, differences in PRAMS participation rates were attenuated. However, participation rates among mothers of deceased infants remain two to four percentage points lower compared with mothers of living infants. Strategies to increase PRAMS participation could inform knowledge about experiences and behaviours before, during and shortly after pregnancy to help reduce infant mortality.

Abortion Surveillance - United States, 2019.

PROBLEM/CONDITION: CDC conducts abortion surveillance to document the number and characteristics of women obtaining legal induced abortions and number of abortion-related deaths in the United States. PERIOD COVERED: 2019. DESCRIPTION OF SYSTEM: Each year, CDC requests abortion data from the central health agencies for 50 states, the District of Columbia, and New York City. For 2019, 49 reporting areas voluntarily provided aggregate abortion data to CDC. Of these, 48 reporting areas provided data each year during 2010-2019. Census and natality data were used to calculate abortion rates (number of abortions per 1,000 women aged 15-44 years) and ratios (number of abortions per 1,000 live births), respectively. Abortion-related deaths from 2018 were assessed as part of CDC's Pregnancy Mortality Surveillance System (PMSS). RESULTS: A total of 629,898 abortions for 2019 were reported to CDC from 49 reporting areas. Among 48 reporting areas with data each year during 2010-2019, in 2019, a total of 625,346 abortions were reported, the abortion rate was 11.4 abortions per 1,000 women aged 15-44 years, and the abortion ratio was 195 abortions per 1,000 live births. From 2018 to 2019, the total number of abortions increased 2% (from 614,820 total abortions), the abortion rate increased 0.9% (from 11.3 abortions per 1,000 women aged 15-44 years), and the abortion ratio increased 3% (from 189 abortions per 1,000 live births). From 2010 to 2019, the total number of reported abortions, abortion rate, and abortion ratio decreased 18% (from 762,755), 21% (from 14.4 abortions per 1,000 women aged 15-44 years), and 13% (from 225 abortions per 1,000 live births), respectively. In 2019, women in their 20s accounted for more than half of abortions (56.9%). Women aged 20-24 and 25-29 years accounted for the highest percentages of abortions (27.6% and 29.3%, respectively) and had the highest abortion rates (19.0 and 18.6 abortions per 1,000 women aged 20-24 and 25-29 years, respectively). By contrast, adolescents aged <15 years and women aged ≥40 years accounted for the lowest percentages of abortions (0.2% and 3.7%, respectively) and had the lowest abortion rates (0.4 and 2.7 abortions per 1,000 women aged <15 and ≥40 years, respectively). However, abortion ratios in 2019 were highest among adolescents (aged ≤19 years) and lowest among women aged 25-39 years. Abortion rates decreased from 2010 to 2019 for all women, regardless of age. The decrease in abortion rate was highest among adolescents compared with any other age group. From 2018 to 2019, abortion rates decreased or did not change among women aged ≤24 years; however, the abortion rate increased among those aged ≥25 years. Abortion ratios also decreased or did not change from 2010 to 2019 for all age groups, except adolescents aged <15 years. The decrease in abortion ratio was highest among women aged ≥40 years compared with any other age group. From 2018 to 2019, abortion ratios increased for all age groups, except adolescents aged <15 years. In 2019, 79.3% of abortions were performed at ≤9 weeks' gestation, and nearly all (92.7%) were performed at ≤13 weeks' gestation. During 2010-2019, the percentage of abortions performed at >13 weeks' gestation remained consistently low (≤9.0%). In 2019, the highest proportion of abortions were performed by surgical abortion at ≤13 weeks' gestation (49.0%), followed by early medical abortion at ≤9 weeks' gestation (42.3%), surgical abortion at >13 weeks' gestation (7.2%), and medical abortion at >9 weeks' gestation (1.4%); all other methods were uncommon (<0.1%). Among those that were eligible (≤9 weeks' gestation), 53.7% of abortions were early medical abortions. In 2018, the most recent year for which PMSS data were reviewed for pregnancy-related deaths, two women died as a result of complications from legal induced abortion. INTERPRETATION: Among the 48 areas that reported data continuously during 2010-2019, overall decreases were observed during 2010-2019 in the total number, rate, and ratio of reported abortions; however, from 2018 to 2019, 1%-3% increases were observed across all measures. PUBLIC HEALTH ACTION: Abortion surveillance can be used to help evaluate programs aimed at promoting equitable access to patient-centered quality contraceptive services in the United States to reduce unintended pregnancies.

Changes in U.S. Healthcare Provider Practices Related to Emergency Contraception.

INTRODUCTION: Emergency contraception (EC), including EC pills (ECPs) and the copper intrauterine device, can prevent pregnancy after sexual encounters in which contraception was not used or used incorrectly. The U.S. Selected Practice Recommendations for Contraceptive Use (U.S. SPR), initially released in 2013, provides evidence-based clinical recommendations on the provision of EC. The objective of this analysis was to assess the percentage of health care providers reporting frequent provision of select EC practices around the time of and after the release of the U.S. SPR. METHODS: We conducted two cross-sectional mailed surveys using different nationwide samples of office-based physicians and public-sector providers in 2013 and 2014 (n = 2,060) and 2019 (n = 1,420). We compared the percentage of providers reporting frequent provision of select EC practices by time period, overall, and by provider type. RESULTS: In 2019, few providers frequently provided an advance prescription for ECPs (16%), an advance supply of ECPs (7%), or the copper intrauterine device as EC (8%), although 41% frequently provided or prescribed regular contraception at the same time as providing ECPs. Providers in 2019 were more likely than providers in 2013 and 2014 to provide or prescribe contraception at the same time as providing ECPs (adjusted prevalence ratio, 1.26; 95% confidence interval, 1.001-1.59) and to provide a copper intrauterine device as EC (adjusted prevalence ratio, 3.87; 95% confidence interval 2.10-7.15); there were no other significant differences by time period. CONCLUSIONS: Few providers report frequent implementation of recommended EC practices. Understanding the barriers faced by providers and clinics in implementing these practices may improve access to EC.

COVID-19 and Sexual and Reproductive Health Care: Findings From Primary Care Providers Who Serve Adolescents.

PURPOSE: Among U.S. primary care physicians who delivered sexual and reproductive health (SRH) services to adolescents before the COVID-19 pandemic, we examine (1) changes in availability of in-person SRH services; (2) changes in accessibility and utilization of SRH services; and (3) use of strategies to support provision of SRH services during the pandemic. METHODS: Data were from the DocStyles provider survey administered September-October 2020. Descriptive analyses were restricted to family practitioners, internists, and pediatricians whose main work setting was outpatient and whose practice provided family planning or sexually transmitted infection services to ≥ one patient aged 15-19 years per week just before the COVID-19 pandemic (n = 791). RESULTS: Among physicians whose practices provided intrauterine device/implant placement/removal or clinic-based sexually transmitted infection testing before the COVID-19 pandemic, 51% and 36% indicated disruption of these services during the pandemic, respectively. Some physicians also reported reductions in walk-in hours (38%), evening/weekend hours (31%), and adolescents seeking care (43%) in the past month. At any point during the pandemic, 61% provided contraception initiation/continuation and 44% provided sexually transmitted infection services via telehealth. Among these physicians, about one-quarter reported confidentiality concerns with telehealth in the past month. There were small increases or no changes in other strategies to support contraceptive care. CONCLUSIONS: Findings suggest disruption of certain SRH services and issues with access because of the pandemic among primary care providers who serve adolescents. There are opportunities to enhance implementation of confidential telehealth services and other service delivery strategies that could help promote adolescent SRH in the United States.

COVID-19 and family planning service delivery: Findings from a survey of U.S. physicians.

Equitable access to contraception is critical for reproductive autonomy. Using cross-sectional data from the DocStyles survey administered September-October 2020 (68% response rate), we compared changes in family planning-related clinical services and healthcare delivery strategies before and during the COVID-19 pandemic and assessed service provision issues among 1063 U.S. physicians whose practice provided family planning services just before the pandemic. About one-fifth of those whose practices provided the following services or strategies just before the pandemic discontinued these services during the pandemic: long-acting reversible contraception (LARC) placement (16%); LARC removal (17%); providing or prescribing emergency contraceptive pills (ECPs) in advance (18%); and reminding patients about contraception injections or LARC removal or replacement (20%). Many practices not providing the following services or strategies just before the pandemic initiated these services during the pandemic: telehealth for contraception initiation (43%); telehealth for contraception continuation (48%); and renewing contraception prescriptions without requiring an office visit (36%). While a smaller proportion of physicians reported service provision issues in the month before survey completion than at any point during the pandemic, about one-third still reported fewer adult females seeking care (37%) and technical challenges with telehealth (32%). Discontinuation of key family planning services during the COVID-19 pandemic may limit contraception access and impede reproductive autonomy. Implementing healthcare service delivery strategies that reduce the need for in-person visits (e.g., telehealth for contraception, providing or prescribing ECPs in advance) may decrease disruptions in care. Resources exist for public health and clinical efforts to ensure contraception access during the pandemic.

Need for Contraceptive Services Among Women of Reproductive Age - 45 Jurisdictions, United States, 2017-2019.

Ensuring access to contraceptive services is an important strategy for preventing unintended pregnancies, which account for nearly one half of all U.S. pregnancies (1) and are associated with adverse maternal and infant health outcomes (2). Equitable, person-centered contraceptive access is also important to ensure reproductive autonomy (3). Behavioral Risk Factor Surveillance System (BRFSS) data collected during 2017-2019 were used to estimate the proportion of women aged 18-49 years who were at risk for unintended pregnancy* and had ongoing or potential need for contraceptive services.† During 2017-2019, in the 45 jurisdictions§ from which data were collected, 76.2% of women aged 18-49 years were considered to be at risk for unintended pregnancy, ranging from 67.0% (Alaska) to 84.6% (Georgia); 60.7% of women had ongoing or potential need for contraceptive services, ranging from 45.3% (Puerto Rico) to 73.7% (New York). For all jurisdictions combined, the proportion of women who were at risk for unintended pregnancy and had ongoing or potential need for contraceptive services varied significantly by age group, race/ethnicity, and urban-rural status. Among women with ongoing or potential need for contraceptive services, 15.2% used a long-acting reversible method (intrauterine device or contraceptive implant), 25.0% used a short-acting reversible method (injectable, pill, transdermal patch, or vaginal ring), and 29.5% used a barrier or other reversible method (diaphragm, condom, withdrawal, cervical cap, sponge, spermicide, fertility-awareness-based method, or emergency contraception). In addition, 30.3% of women with ongoing or potential need were not using any method of contraception. Data in this report can be used to help guide jurisdictional planning to deliver contraceptive services, reduce unintended pregnancies, ensure that the contraceptive needs of women and their partners are met, and evaluate efforts to increase access to contraception.

Update to U.S. Selected Practice Recommendations for Contraceptive Use: Self-Administration of Subcutaneous Depot Medroxyprogesterone Acetate.

U.S. Selected Practice Recommendations for Contraceptive Use (U.S. SPR), adapted by CDC from global guidance developed by the World Health Organization (WHO), provides evidence-based guidance on contraceptive use for U.S. health care providers (1). During January-February, 2021, CDC evaluated the 2019 WHO recommendation on self-administered subcutaneous depot medroxyprogesterone acetate (DMPA-SC) (2). CDC adopted the WHO recommendation on the basis of moderate-certainty evidence that self-administered DMPA-SC is safe and effective, and has higher continuation rates compared with provider-administered DMPA. The new U.S. SPR recommendation states that self-administered DMPA-SC should be made available as an additional approach to deliver injectable contraception. Provider-administered DMPA should remain available. Self-administered DMPA-SC is a user-controlled method that has the potential to improve contraceptive access and increase reproductive autonomy. Self-administered DMPA-SC should be offered in a noncoercive manner through a shared decision-making process between patients and their health care providers, with a focus on patient preferences and equitable access to the full range of contraceptive methods.

Required examinations and tests before initiating contraception: Provider practices from a national cross-sectional survey.

OBJECTIVE(S): We estimated the prevalence of requiring specific examinations or tests before providing contraception in a nationwide survey of family planning providers. STUDY DESIGN: We conducted a cross-sectional survey of public-sector health centers and office-based physicians providing family planning services across the United States in 2019 (n = 1395). We estimated the weighted proportion of providers (or their health center or practice) who required blood pressure measurement, pelvic examination (bimanual examination and cervical inspection), Papanicolaou (Pap) smear, clinical breast examination (CBE), and chlamydia and gonorrhea (CT/GC) screening before initiating hormonal or intrauterine contraception (IUC) for healthy women. We performed multivariable regression to identify factors associated with pelvic examination practices aligned with clinical recommendations; these recommendations classify examinations and tests as recommended or unnecessary before initiation of specific contraceptive methods. RESULTS: The overall response rate was 51%. Most providers required blood pressure measurement before initiating each method. Unnecessary CBE, Pap smears, and CT/GC screening were required by 14% to 33% of providers across methods. Fifty-two to 62% of providers required recommended pelvic examination before IUC placement; however, 16% to 23% of providers required unnecessary pelvic examinations before non-intrauterine hormonal method initiation. Factors associated with recommendation-aligned pelvic examination practices included having a higher proportion of patients using public funding (Medicaid or other assistance) and more recently completing formal clinical training. CONCLUSIONS: Almost half (47%) of providers did not require necessary pelvic examination before placing IUC. Conversely, many providers required unnecessary examinations and tests before contraception initiation for patients. IMPLICATIONS: Most providers required the few recommended examinations and tests for safe contraceptive provision. Reduction of unnecessary examinations and tests may reduce barriers to contraceptive access. There are also opportunities to increase use of recommended examinations, as up to 48% of providers did not require recommended pelvic examination before IUC.

Removing Unnecessary Medical Barriers to Contraception: Celebrating a Decade of the U.S. Medical Eligibility Criteria for Contraceptive Use.

In 2010, the Centers for Disease Control and Prevention (CDC) released the U.S. Medical Eligibility Criteria for Contraceptive Use, providing recommendations for health care providers on safe use of contraception for people with certain characteristics or medical conditions. Adapted from World Health Organization guidance, the goal of the recommendations is to remove unnecessary medical barriers to contraception. Over the past decade, CDC has updated recommendations based on new evidence, collaborated with national partners to disseminate and implement the guidelines, and conducted provider surveys to assess changes in attitudes and practices around contraception safety and provision. CDC remains committed to supporting evidence-based guidelines for safe use of contraception, as the basis for improving access to contraception and high-quality family planning services, reducing unintended pregnancy, and improving reproductive health in the United States.