Reproductive Health and Coronavirus Disease 2019-Induced Economic Contracture: Lessons From the Great Recession.

The coronavirus disease 2019 (COVID-19) pandemic has magnified disparities in care, including within reproductive health. There has been limited research on the implications of the financial calamity COVID-19 has precipitated on reproductive health, including restricted access to contraception and prenatal care, as well as adverse perinatal outcomes resulting from economic contracture. We therefore examined the Great Recession (the period of economic downturn from 2007-2009 also referred to as the 2008 recession) to discuss how the current financial difficulties may influence reproductive health now and in the years to come. The existing literature examining the impacts of economic downturn on reproductive health provides a resounding body of evidence supporting the need for state and federal investment in comprehensive reproductive health care. Policies directed at expanding access to programs such as Special Supplemental Nutrition Program for Women, Infants, and Children and Medicaid (WIC), extending Medicaid coverage to 12 months' postpartum, continuing coverage for telehealth services, and lowering barriers to access through mobile care units would help mitigate anticipated effects of a recession on reproductive health.

Variation in the interpretation and application of the Medicaid sterilization consent form among Medicaid officials.

OBJECTIVE: The Medicaid consent policy has been identified as a major barrier to desired permanent contraception, particularly for low-income communities and communities of color. As each state may modify their state Medicaid sterilization consent form, variation in the form has been reported. This study aims to characterize state-level variation in Medicaid Title XIX consent form interpretation and application. STUDY DESIGN: We aimed to collect primary data from Medicaid officials in all 50 United States from January to May 2020 via a 25-question electronic survey regarding state-level consent form implementation. Questions targeted consent form details and definitions, insurance and billing, clinician correspondence, and administrative processes. We used Qualtrics XM to collect survey responses. We performed descriptive statistics on the survey responses. There were no exclusion criteria. RESULTS: We had 41 responses from 36/50 states (72% participation rate). Heterogeneity existed in the key definitions of "Premature Delivery" and "Emergency Abdominal Surgery." One in five respondents reported the consent form was only available in English. Variation among Current Procedural Terminology codes covered in each state's sterilization policy were noted. Nearly a quarter of respondents did not know how Medicaid informed healthcare providers of consent form denials. Most participants (90%) were unaware of differences between state sterilization policies. CONCLUSION: This study demonstrates variation in terms of consent form definitions, procedures covered, correspondence with clinicians, and administrative review processes among state Medicaid offices regarding the sterilization consent form. Greater transparency is necessary in order to reduce administrative barriers to desired permanent contraception. IMPLICATIONS: Inconsistent interpretation poses an administrative barrier to care, raises concern regarding appropriate clinician reimbursement, and can potentially lead to unnecessarily denying patients the contraceptive option of their choice. Permanent contraception policies should be equitable no matter insurance status, preserve reproductive autonomy and effectively protect vulnerable populations.

Health Equity Morbidity and Mortality Conferences in Obstetrics and Gynecology.

Maternal mortality and morbidity continue to occur at unacceptably high levels in the United States, with communities of color experiencing significantly higher rates than their White counterparts, even after adjustment for confounding factors such as socioeconomic status. Many obstetrics and gynecology departments across the country have begun to incorporate routine discussion and analysis of health equity into peer review and educational processes, including grand rounds and morbidity and mortality conferences. Despite the desire and drive, there is little published guidance on best practices for incorporation of an equity component into these conferences. This document outlines the current processes at four academic institutions to highlight the variety of ways in which health equity and social justice can be incorporated when analyzing patient experiences and health outcomes. This commentary also provides a list of specific recommendations based on the combined experiences at these institutions so that others across the country can incorporate principles of health equity into their peer-review processes.

Contraceptive Care Disparities Among Sexual Orientation Identity and Racial/Ethnic Subgroups of U.S. Women: A National Probability Sample Study.

Background: Sexual minority women may use contraception for various reasons but face notable barriers to contraceptive care, including stigma and discrimination. However, studies examining sexual orientation disparities in contraceptive care have largely relied on nonprobability samples of predominately White women and may thus not be generalizable to U.S. women overall or Black and Latina women in particular. Materials and Methods: Using data from the 2006 to 2017 National Survey of Family Growth, a large national probability sample of U.S. women 15-44 years of age (N = 25,473), we used multivariable logistic regression to estimate adjusted odds ratios for receiving a contraceptive method or prescription and contraceptive counseling from a health care provider in the past year among sexual orientation identity and racial/ethnic subgroups of heterosexual, bisexual, and lesbian White, Black, and Latina women relative to White heterosexual women. Results: Among women overall, 33.9% had received contraception and 18.3% had obtained contraceptive counseling. Black (odds ratio [OR] = 0.73, 95% confidence interval [CI]: 0.65-0.82) and Latina (OR = 0.73, 95% CI: 0.64-0.82) heterosexual women, White (OR = 0.80, 95% CI: 0.65-0.99) and Black (OR = 0.43, 95% CI: 0.32-0.58) bisexual women, and White (OR = 0.23, 95% CI: 0.13-0.43), Black (OR = 0.19, 95% CI: 0.09-0.40), and Latina (OR = 0.08, 95% CI: 0.03-0.22) lesbian women had significantly lower adjusted odds of receiving contraception compared with White heterosexual women. White (OR = 0.36, 95% CI: 0.15-0.85), Black (OR = 0.42, 95% CI: 0.18-0.98), and Latina (OR = 0.22, 95% CI: 0.09-0.53) lesbian women also had significantly lower adjusted odds of obtaining contraceptive counseling relative to White heterosexual women. Conclusions: Policies, programs, and practices that facilitate access to person-centered contraceptive care among marginalized sexual orientation identity and racial/ethnic subgroups of U.S. women are needed to promote reproductive health equity.

COVID-19 highlights the policy barriers and complexities of postpartum sterilization.

Multiple barriers exist to sterilization in the postpartum period. One such barrier, the Medicaid Title XIX sterilization policy, requires publicly insured patients to complete a sterilization consent form at least 30 days prior to their scheduled procedure. While this policy was set in place in the 1970s to address the practice of coerced sterilization among marginalized women, it has served as a significant barrier to obtaining the procedure in the contemporary period. The COVID-19 pandemic has highlighted specific complexities surrounding postpartum sterilization and created additional barriers for women desiring this contraceptive method. Despite the time constraints to perform postpartum sterilization, some hospital administrators, elective officials, and state Medicaid offices deemed sterilization as "elective." Additionally, as the Center for Medicare and Medicaid Services (CMS) has revised telemedicine reimbursement and encouraged its increased use, it has provided no guidance for the sterilization consent form, use of oral consents, and change to the sterilization consent form expiration date. This leaves individual states to create policies and recommended procedures that may not be accepted or recognized by CMS. These barriers put significant strain on patients attempting to obtain postpartum sterilization, specifically for patients with lower incomes and women of color. CMS can support reproductive health for vulnerable populations by providing clear guidance to state Medicaid offices, extending the 180-day expiration of a sterilization consent form signed prior to the pandemic, and allowing for telemedicine oral consents with witnesses or electronic signatures.

Illuminating the bacterial microbiome of Australian ticks with 16S and Rickettsia-specific next-generation sequencing.

Next-generation sequencing (NGS) studies show that mosquito and tick microbiomes influence the transmission of pathogens, opening new avenues for vector-borne pathogen control. Recent microbiological studies of Australian ticks highlight fundamental knowledge gaps of tick-borne agents. This investigation explored the composition, diversity and prevalence of bacteria in Australian ticks (n = 655) from companion animals (dogs, cats and horses). Bacterial 16S NGS was used to identify most bacterial taxa and a Rickettsia-specific NGS assay was developed to identify Rickettsia species that were indistinguishable at the V1-2 regions of 16S. Sanger sequencing of near full-length 16S was used to confirm whether species detected by 16S NGS were novel. The haemotropic bacterial pathogens Anaplasma platys, Bartonella clarridgeiae, "Candidatus Mycoplasma haematoparvum" and Coxiella burnetii were identified in Rhipicephalus sanguineus (s.l.) from Queensland (QLD), Western Australia, the Northern Territory (NT), and South Australia, Ixodes holocyclus from QLD, Rh. sanguineus (s.l.) from the NT, and I. holocyclus from QLD, respectively. Analysis of the control data showed that cross-talk compromises the detection of rare species as filtering thresholds for less abundant sequences had to be applied to mitigate false positives. A comparison of the taxonomic assignments made with 16S sequence databases revealed inconsistencies. The Rickettsia-specific citrate synthase gene NGS assay enabled the identification of Rickettsia co-infections with potentially novel species and genotypes most similar (97.9-99.1%) to Rickettsia raoultii and Rickettsia gravesii. "Candidatus Rickettsia jingxinensis" was identified for the first time in Australia. Phylogenetic analysis of near full-length 16S sequences confirmed a novel Coxiellaceae genus and species, two novel Francisella species, and two novel Francisella genotypes. Cross-talk raises concerns for the MiSeq platform as a diagnostic tool for clinical samples. This study provides recommendations for adjustments to Illumina's 16S metagenomic sequencing protocol that help track and reduce cross-talk from cross-contamination during library preparation. The inconsistencies in taxonomic assignment emphasise the need for curated and quality-checked sequence databases.

Label-free, High-Resolution Optical Metabolic Imaging of Human Cervical Precancers Reveals Potential for Intraepithelial Neoplasia Diagnosis.

While metabolic changes are considered a cancer hallmark, their assessment has not been incorporated in the detection of early or precancers, when treatment is most effective. Here, we demonstrate that metabolic changes are detected in freshly excised human cervical precancerous tissues using label-free, non-destructive imaging of the entire epithelium. The images rely on two-photon excited fluorescence from two metabolic co-enzymes, NAD(P)H and FAD, and have micron-level resolution, enabling sensitive assessments of the redox ratio and mitochondrial fragmentation, which yield metrics of metabolic function and heterogeneity. Simultaneous characterization of morphological features, such as the depth-dependent variation of the nuclear:cytoplasmic ratio, is demonstrated. Multi-parametric analysis combining several metabolic metrics with morphological ones enhances significantly the diagnostic accuracy of identifying high-grade squamous intraepithelial lesions. Our results motivate the translation of such functional metabolic imaging to in vivo studies, which may enable improved identification of cervical lesions, and other precancers, at the bedside.

Leaving half the population behind-the continued fight to cover America's mothers: a call to action.

For the last century, healthcare coverage in the United States has been a debated topic. The passage of the Social Security Act Amendments and the Patient Protection and Affordable Care Act has improved the available coverage of vulnerable populations, but access to healthcare is still fraught with barriers. This is particularly true for women in the postpartum period. It is widely accepted that the postpartum period is the optimal time to address health issues that developed during pregnancy or predated pregnancy. With more than half of maternal deaths occurring in the year after a birth and disproportionately affecting women of color, the postpartum time period is critical. The United States is the only industrialized country with a rising maternal mortality rate and therefore must take advantage of the 12 months postpartum, or "fourth trimester," to aid in addressing this national health crisis. As an incentivized provision, most states have expanded Medicaid since the signing of the Patient Protection and Affordable Care Act. However, pregnancy-related coverage still ceases after 60 days postpartum. Although states can apply for a waiver to extend this coverage, this process is unnecessarily laborious. The time has far passed for the federal government to act. Presently, there are numerous pieces of legislation before Congress to provide Medicaid coverage for pregnant patients through 365 days postpartum. Insurance coverage alone will not reverse the rising maternal mortality rate in this country, but it is a crucial first step.

Obstetrics-gynecology resident long-acting reversible contraception training: the role of resident and program characteristics.

BACKGROUND: Obstetrics-gynecology residents should graduate with competence in comprehensive contraceptive care, including long-acting reversible contraception. Lack of hands-on training and deficits in provider education are barriers to long-acting reversible contraception access. Identifying the number of long-acting reversible contraception insertions performed by obstetrics-gynecology residents could provide insight into the depth and breadth of long-acting reversible contraception training available to obstetrics-gynecology residents in Accreditation Council for Graduate Medical Education-accredited residency programs. OBJECTIVE: Our study investigates long-acting reversible contraception-specific training in obstetrics-gynecology residency programs across the United States, including the self-reported number of long-acting reversible contraception insertions per resident and the impact of resident demographic characteristics and residency program characteristics on training. STUDY DESIGN: Obstetrics-gynecology residents completed a voluntary electronic survey during the 2016 Council on Resident Education in Obstetrics and Gynecology examination. The survey included resident demographic characteristics and residency program characteristics as well as resident education and training in long-acting reversible contraception (number of intrauterine devices and implants inserted, training in immediate postpartum intrauterine device placement). A binary "long-acting reversible contraception insertion experience" variable dichotomized respondents as having a low level of long-acting reversible contraception insertions (0 implants and/or 10 or fewer intrauterine devices ) or a high level of long-acting reversible contraception insertions (1 or more implants and/or 11 or more intrauterine devices). χ2 tests were used to compare the presence of long-acting reversible contraception insertion experience by postgraduate year, resident demographic characteristics, and residency program characteristics. Adjusted logistic regression was performed to ascertain the independent effects of gender, race/ethnicity (non-Hispanic white vs other), residency program type (university vs community), and residency program geographic region on the likelihood of "low" overall long-acting reversible contraception insertion experience. RESULTS: In total, 5055 obstetrics-gynecology residents completed the survey (85%); analysis included only residents in United States obstetrics-gynecology programs (N=4322). Of the total analytic sample, 1777 (41.2%) had low long-acting reversible contraception insertion experience. As expected, the number of intrauterine device insertions, implant insertions, and overall long-acting reversible contraception experience increased as residents progressed through training. Long-acting reversible contraception insertion experience varied by residency program geographic region: 169 (27.1%) residents in programs in the West had low long-acting reversible contraception insertion experience compared with 498 (39.0%) in the South, 473 (45.3%) in the Midwest, and 615 (46.0%) in the Northeast. Only 152 (14.9%) of all postgraduate year 4 residents had low long-acting reversible contraception insertion experience. Among postgraduate year 4 residents, low long-acting reversible contraception insertion experience was significantly associated racial/ethnic minority status and community-based residency program type (compared with university-based). Postgraduate year 4 residents in programs located in the Northeast and Midwest had 4.25 (95% confidence interval, 2.04-8.85) and 2.75 (95% confidence interval, 1.27-5.97) times the odds of low long-acting reversible contraception experience compared with those in residency programs in the West, even after adjusting for other respondent characteristics and other residency program characteristics. CONCLUSION: Obstetrics-gynecology residents experience a range of long-acting reversible contraception training and insertions, which differed according to resident race/ethnicity and residency program characteristics (program type and geographic region). Residency programs with low long-acting reversible contraception training experience should consider opportunities to improve competence in this fundamental obstetrics-gynecology skill.

Automatic Barcode Gap Discovery reveals large COI intraspecific divergence in Australian Ixodidae.

Ticks (Ixodida) are haematophagous arthropods that transmit a number of pathogenic organisms, including bacteria, protozoa and viruses, to humans and animals. Globally, there are over 900 species of ticks and Australia has 73 described species, including five introduced and 68 native species. With the exception of only a few Australian tick species, there are still many unanswered questions regarding their taxonomy and systematics, and the phylogeny of Australian ticks is not properly resolved. In recent years, a putative link between tick bites and poorly defined tick-borne illness(es) has been identified (Graves Stenos 2017) and was the subject of a 2015 Australian Senate Inquiry into Lyme-like illnesses in Australia. There is an urgent need to further categorise Australian ticks, specifically hard ticks (Ixodidae), and accurate identification of Australian ticks is therefore of high importance.

Cancer Screening in Women.

Advancements in cancer screening techniques have allowed for earlier detection of cancer at premalignant or early stages of disease. Several organizations have guidelines for screening strategies for breast, cervical, colon, and lung cancer. Ovarian cancer remains the deadliest cancer of the female reproductive tract; however, guidelines have yet to be shown effective in identifying ovarian cancer at earlier stages. It is important that providers familiarize themselves with up-to-date screening strategies in women at average risk and at increased risk of disease. The provider's role in guiding patients toward screening programs and counseling regarding risk reduction is one of the most important.

Parental consent: an unnecessary barrier to adolescent obstetrical care.

When adolescents in the United States become pregnant, these young mothers experience differential access to obstetrical services, including prenatal, intrapartum, and postpartum care. As of 2018, 13 states in the United States do not afford a pregnant minor rights to prenatal care without parental consent, and 13 states do not ensure confidentiality from parental disclosure. Because of this, young mothers may avoid seeking timely and medically necessary care, not to mention counseling regarding preventive health services and monitoring of underlying chronic conditions. Lack of access during these critical months leads to missed essential opportunities for intervention and increased pregnancy-related risks to the mother and infant. It is imperative for obstetricians and gynecologists to value, support, and advocate for adolescents' emerging autonomy and personal agency to make informed decisions about their own bodies during their pregnancies, but also in making the choice to prevent future pregnancies through contraception.

Use of Long-Acting Reversible Contraception by Obstetrics and Gynecology Residents: An Examination of Access for All Women.

Although long-acting reversible contraception (LARC) use is increasing in the general female population, only 12% of all women who use contraception and 4.8% of nulliparous women in the United States use either the intrauterine device (IUD) or contraceptive implant. In several studies, however, female physicians prefer LARC for contraception. In 2016, an anonymous electronic survey was administered to all U.S. obstetrics and gynecology residents before the start of the annual in-training examination administered by the Council on Resident Education in Obstetrics and Gynecology. The survey included questions about LARC, including personal use. Fifty percent of female residents or the female partners of male residents used IUDs for contraception, 31.3% used combined oral contraceptives, and 3% used a contraceptive implant. Among nulliparous residents, 37.7% used IUDs. This rate of IUD use was five times the rate reported by the general female population and eight times the nulliparous rate in the United States. Obstetrics and gynecology residents understand the benefits of LARC, but have minimal barriers to access. When barriers and cost are removed and the full range of contraceptive options is offered, the majority of contracepting women and adolescents choose LARC. With the high rates of unintended pregnancy and maternal morbidity and mortality in the United States-especially among poor and minority women-all women, regardless of income, race-ethnicity, and career, should have awareness of and access to these effective contraceptive methods.

Training Physicians in Advocacy: Why It Matters.

At a time in our country's history when state and federal legislative regulations on medical practice and access to services are at an all-time high, effective physician advocacy in women's health is crucial to the evolution of our profession and the provision of quality and equitable patient care. Inclusion of specific advocacy training programs in residency and beyond should be considered a priority. Ensuring a unified set of goals for advocacy training is important to training the next generation of competent and skilled physician advocates for leadership in academia and professional organizations. Sharing of initiatives and efforts to integrate advocacy into the training continuum across our community may inspire broader acceptance and implementation of such programs.