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PURPOSE: We sought to understand how patients and physicians conceptualize uncertainty in the permanent contraception decision-making process. BASIC PROCEDURES: In 2022-2023, we interviewed postpartum patients with a documented desire for permanent contraception (n = 81) and their delivering physicians (n = 67). Eligible patients gave birth at one of our four study hospitals in California, Ohio, Illinois, and Alabama. We used rapid content analysis and thematic content analysis to develop and refine themes related to uncertainty in permanent contraceptive decision-making. MAIN FINDINGS: Most patients reported full certainty in their decision regarding permanent contraception, although some expressed doubts. After receiving permanent contraception, some patients discussed grief but overall affirmed their decision. One patient said they wished they had considered other contraceptive options. Physicians reported using a range of strategies to safeguard from patient regret, including ensuring patients were 100% certain with their decision, inferring certainty based on their characteristics, asking patients to think through all scenarios that could affect decision-making, and repeat counseling during multiple interactions. PRINCIPAL CONCLUSIONS: Patient experiences reveal the depth, fluidity, and nuance of patients' contraceptive decision-making processes. Physicians sometimes failed to grapple with this nuance by centering potential regret in their counseling. Personalized and supportive contraceptive counseling that acknowledges the complexity of contraceptive decision-making is imperative. Shared decision-making can help ensure patients can make informed and autonomous decisions about their reproductive lives.
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Objectives. To assess the associations between the executive order that Texas governor Greg Abbott issued on March 22, 2020, postponing procedures deemed not immediately medically necessary, and patients' access to abortion care in Texas. Methods. We used 17 515 individual-level patient records from 13 Texas abortion facilities for matched periods in 2019 and 2020 to examine differences in return rates for abortion after completion of a state-mandated ultrasound and median wait times between ultrasound and abortion visits for those who returned. Results. Patients were less likely to return for an abortion if they had an ultrasound while the executive order was under effect (82.8%) than in the same period in 2019 (90.4%; adjusted odds ratio = 2.06; 95% confidence interval = 1.12, 3.81). Compared with patients at or before 10.0 weeks' gestation at ultrasound, patients at more than 10 weeks' gestation had higher odds of not returning for an abortion or, if they returned, experienced greater wait times between ultrasound and abortion visits. Conclusions. Texas' executive order prohibiting abortion during the COVID-19 pandemic disrupted patients' access to care and disproportionately affected patients who were past 10 weeks' gestation. (Am J Public Health. Published online ahead of print August 15, 2024:e1-e11. https://doi.org/10.2105/AJPH.2024.307747).
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This Viewpoint describes the failure of yet another state institution to generate meaningful guidance about medical exceptions to abortion bans.
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Aborto Legal , Atenção à Saúde , Conselho Diretor , Serviços de Saúde Materna , Complicações na Gravidez , Feminino , Humanos , Gravidez , Aborto Induzido/ética , Aborto Induzido/legislação & jurisprudência , Aborto Legal/ética , Aborto Legal/legislação & jurisprudência , Futilidade Médica/legislação & jurisprudência , Futilidade Médica/ética , Texas/epidemiologia , Conselho Diretor/ética , Conselho Diretor/legislação & jurisprudência , Mortalidade Materna , Serviços de Saúde Materna/ética , Serviços de Saúde Materna/legislação & jurisprudência , Serviços de Saúde Materna/normas , Complicações na Gravidez/mortalidade , Complicações na Gravidez/cirurgia , Atenção à Saúde/ética , Atenção à Saúde/legislação & jurisprudência , Atenção à Saúde/normas , Qualidade da Assistência à Saúde/ética , Qualidade da Assistência à Saúde/legislação & jurisprudência , Qualidade da Assistência à Saúde/normasRESUMO
INTRODUCTION: Medication abortion is safe and effective, but restrictions still limit patients from accessing this method. Alternative models of medication abortion provision, namely advance provision, over-the-counter (OTC), and online, could help improve access to care for some, although there is limited evidence about abortion patients' interest in these models. METHODS: Between 2017 and 2019, we administered a cross-sectional survey to abortion patients at 45 clinics across 15 U.S. states to explore their interest in and support for advance provision, OTC, and online abortion access. We assessed relationships between sociodemographic characteristics and interest in and support for each model using bivariate logistic regressions and present perceived advantages and disadvantages of each model, as described by a subset of participants. RESULTS: Among 1,965 people enrolled, 1,759 (90%) initiated the survey. Interest in and support for advance provision was highest (72% and 82%, respectively), followed by OTC (63% and 72%) and online access (57% and 70%). In bivariate analyses, non-Hispanic Black and Asian/Pacific Islander respondents expressed lower interest and support for the online model and Alaska Native/Native American respondents expressed higher interest in an OTC model, as compared with white respondents. Among 439 participants naming advantages and disadvantages of each model, the most common advantages included convenience and having the abortion earlier. The most common disadvantages were not seeing a provider first and possibly taking pills incorrectly. CONCLUSIONS: Although most abortion patients expressed interest in and support for alternative models of medication abortion provision, variation in support across race/ethnicity highlights a need to ensure that abortion care service models meet the needs and preferences of all patients, particularly people from historically underserved populations.
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Aborto Induzido , Acessibilidade aos Serviços de Saúde , Medicamentos sem Prescrição , Humanos , Feminino , Estados Unidos , Adulto , Estudos Transversais , Gravidez , Inquéritos e Questionários , Medicamentos sem Prescrição/uso terapêutico , Adolescente , Adulto Jovem , Abortivos/uso terapêuticoRESUMO
This cross-sectional study estimates the incidence of rape-related pregnancies in US states with abortion bans.
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Aborto Induzido , Estupro , Gravidez , Feminino , Humanos , Aborto Legal , SobreviventesRESUMO
OBJECTIVE: To assess pregnant Texans' decisions about where to obtain out-of-state abortion care following the September 2021 implementation of Senate Bill 8 (SB8), which prohibited abortions after detectable embryonic cardiac activity. DATA SOURCE: In-depth telephone interviews with Texas residents ≥15 years of age who obtained out-of-state abortion care after SB8's implementation. STUDY DESIGN: This qualitative study explored participants' experiences identifying and contacting abortion facilities and their concerns and considerations about traveling out of state. We used inductive and deductive codes in our thematic analysis describing people's decisions about where to obtain care and how they evaluated available options. DATA COLLECTION: Texas residents self-referred to the study from flyers we provided to abortion facilities in Arkansas, Colorado, Kansas, Louisiana, Mississippi, New Mexico, and Oklahoma. We also enrolled participants from a concurrent online survey of Texans seeking abortion care. PRINCIPAL FINDINGS: Participants (n = 65) frequently obtained referral lists for out-of-state locations from health-care providers, and a few received referrals to specific facilities; however, referrals rarely included the information people needed to decide where to obtain care. More than half of the participants prioritized getting the soonest appointment and often contacted multiple locations and traveled further to do so; others who could not travel further typically waited longer for an appointment. Although the participants rarely cited state abortion restrictions or cost of care as their main reason for choosing a location, they often made sacrifices to lessen the logistical and economic hardships that state restrictions and out-of-state travel costs created. Informative abortion facility websites and compassionate scheduling staff solidified some participants' facility choice. CONCLUSIONS: Pregnant Texans made difficult trade-offs and experienced travel-related burdens to obtain out-of-state abortion care. As abortion bans prohibit more people from obtaining in-state care, efforts to strengthen patient navigation are needed to reduce care-seeking burdens as this will support people's reproductive autonomy.
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Aborto Induzido , Viagem , Gravidez , Feminino , Humanos , Texas , Acessibilidade aos Serviços de Saúde , Doença Relacionada a Viagens , Tomada de DecisõesRESUMO
OBJECTIVES: Following the implementation of a restrictive abortion law in Texas (Senate Bill 8), we conducted in-depth interviews with pregnant people about their experiences seeking abortion care. In this analysis, we explore participants' motivations for taking part in a research study. STUDY DESIGN: Between October 2021 and August 2022, we conducted 120 in-depth interviews with Texans (aged ≥15 years) who, after considering abortion, had a facility-based abortion, self-managed their abortion, experienced miscarriage or ectopic pregnancy, or continued their pregnancy. We asked all interviewees, "Why did you decide to participate in the interview?" For analysis, we used inductive and deductive coding approaches to explore motivations for and concerns about participation. RESULTS: Most commonly, interviewees appreciated the opportunity to share their stories, frequently describing how their experiences highlight the nuance of abortion decision-making and challenge stigmatized views about abortion. Some described an emotional benefit of participating, as they had no one else to whom to disclose their experience without judgment. Many hoped to help others by participating, saying that access to other people's stories would have helped them feel less isolated. Relatedly, many viewed their participation as an opportunity to speak out against restrictive policies that caused them harm, hardship, and distress. Interviewees seldom cited the monetary incentive alone as motivation for participation. A few expressed concerns about participating out of fear of legal repercussions for others involved in their abortion process (e.g., ride-share driver). These themes were consistent across pregnancy outcomes. CONCLUSIONS: Research volunteers are motivated to participate for altruistic and self-benefiting reasons. IMPLICATIONS: This study provides insights into what people seeking abortion consider when deciding to participate in qualitative research. Research ethics committees evaluating and researchers conducting abortion research should weigh these motivations, perceived benefits, and concerns. Policies that enhance protections for participant data are needed to support knowledge generation from abortion research.
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Aborto Induzido , Aborto Espontâneo , Gravidez , Feminino , Humanos , Aborto Induzido/psicologia , Resultado da Gravidez , Emoções , Texas , Pesquisa QualitativaRESUMO
This qualitative study conducted between November 2020 and March 2021 in the US state of Mississippi examines the experiences of 25 people who obtained medication abortion at the state's only abortion facility. We conducted in-depth interviews with participants after their abortions until concept saturation was reached, and then analysed the content using inductive and deductive analysis. We assessed how people use embodied knowledge about their individual physical experiences such as pregnancy symptoms, a missed period, bleeding, and visual examinations of pregnancy tissue to identify the beginning and end of pregnancy. We compared this to how people use biomedical knowledge such as pregnancy tests, ultrasounds, and clinical examinations to confirm their self-diagnoses. We found that most people felt confident that they could identify the beginning and end of pregnancy through embodied knowledge, especially when combined with the use of home pregnancy tests that confirmed their symptoms, experiences, and visual evidence. All participants concerned about symptoms sought follow-up care at a medical facility, whereas people who felt confident of the successful end of the pregnancy did so less often. These findings have implications for settings of restricted abortion access that have limited options for follow-up care after medication abortion.
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Aborto Induzido , Gravidez , Feminino , Humanos , Instalações de Saúde , Emoções , Pesquisa Qualitativa , MississippiRESUMO
OBJECTIVES: We assessed Mississippi abortion clients' perceptions of alternative medication abortion service delivery options that were restricted under state law but available elsewhere. METHODS: We conducted in-depth interviews with medication abortion clients between November 2020 and March 2021 at Mississippi's only abortion facility. We described alternative service delivery models: telemedicine, medications by mail, and follow-up care in their community versus returning to the facility. We asked if participants would be interested in using any of these models, if available, and how use of each model would have changed their abortion experience. We used thematic analysis, organizing codes into common themes based on participants' preferences and concerns for each option. RESULTS: Of the 25 participants interviewed, nearly all (n = 22) expressed interest in at least one option and reported that, had they been available, these would have alleviated cost, travel, and childcare barriers. Many believed these options would further ensure privacy, but a minority thought abortion was too sensitive for telemedicine or were concerned about mailing errors. Participants not interested in the alternative options also feared missing valued aspects of face-to-face care. Most did not return to the facility for follow-up (n = 19), citing financial and logistical barriers. Largely, participants were not interested in obtaining follow-up care in their community, citing concerns about provider judgment, stigma, and privacy. CONCLUSIONS: Mississippi abortion clients were interested in models that would make abortion care more convenient while ensuring their privacy and allowing for meaningful client-provider interaction. These features of care should guide the development of strategies aimed at helping those in restricted settings, such as Mississippi, to overcome barriers to abortion care following the implementation of abortion bans in many states following the overturn of Roe v. Wade.
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Aborto Induzido , Telemedicina , Gravidez , Feminino , Humanos , MississippiRESUMO
OBJECTIVES: This study aimed to explore Planned Parenthood Medicaid patients' experiences getting reproductive health care in Texas after the state terminated Planned Parenthood providers from its Medicaid program in 2021. STUDY DESIGN: Between January and September 2021, we recruited Medicaid patients who obtained care at Planned Parenthood health centers prior to the state termination using direct mailers, electronic messages, community outreach, and flyers in health centers. We conducted baseline and 2-month follow-up semistructured phone interviews about patients' previous experiences using Medicaid at Planned Parenthood and other providers and how the termination affected their care. We qualitatively analyzed the data using the principles of grounded theory. RESULTS: We interviewed 30 patients, 24 of whom completed follow-up interviews. Participants reported that Planned Parenthood reliably accepted different Medicaid plans, worked with patients to ameliorate the structural barriers they face to care, and referred them to other providers as needed. After Planned Parenthood's termination from the Texas Medicaid program, participants faced difficulties accessing care elsewhere, including same-day appointments and on-site medications. Consequences included delayed or forgone reproductive health care, including contraception, and emotional distress. CONCLUSIONS: Planned Parenthood Medicaid patients found it difficult to connect with other providers for reproductive health care and to obtain evidence-based care following the organization's termination from Medicaid. Ensuring all Medicaid patients have freedom to choose providers would improve access to quality contraception and other reproductive health care. IMPLICATIONS: Medicaid-funded reproductive health care access is restricted for people living on low incomes when providers do not reliably accept all Medicaid plans or cannot participate in Medicaid. This situation can lead to lower quality care, delayed or forgone care, and emotional distress.
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Serviços de Planejamento Familiar , Medicaid , Estados Unidos , Humanos , Texas , Anticoncepção , Acessibilidade aos Serviços de SaúdeRESUMO
BACKGROUND: Young people's ability to use their preferred contraceptive method is an indicator of reproductive autonomy and healthcare access. State policies can hinder or facilitate access to a preferred contraceptive method. OBJECTIVE: This study compared use of preferred contraceptive method in Texas and California, states with contrasting health policy contexts that impact health insurance coverage and access to subsidized family planning services. METHODS: We used baseline survey data from an ongoing cluster randomized controlled trial of sexually active students, assigned female at birth, ages 18-25, at 29 community colleges in Texas and California (N = 1,974). We described contraceptive preferences and use, as well as reasons for nonuse of a preferred method. We conducted multivariable-adjusted mixed-effects logistic regression analyses for clustered data, and then calculated the predicted probability of using a preferred contraceptive method in Texas and California by insurance status. RESULTS: More Texas participants were uninsured than Californians (30% vs. 8%, p<0.001). Thirty-six percent of Texas participants were using their preferred contraceptive method compared to 51% of Californians. After multivariable adjustments, Texas participants had lower odds of using their preferred method (adjusted odds ratio = 0.62, 95% confidence interval = 0.48-0.81) compared to those in California. Texas participants in all insurance categories had a lower predicted probability of preferred method use compared to California participants. In Texas, we found a 12.1 percentage-point difference in the predicted probability of preferred method use between the uninsured (27.5%) and insured (39.6%) (p<0.001). Texans reported financial barriers to using their preferred method more often than Californians (36.7% vs. 19.2%, p<0.001) as did the uninsured compared to the insured (50.9% vs. 18.7%, p<0.001). CONCLUSION: These findings present new evidence that state of residence plays an important role in young people's ability to realize their contraceptive preference. Young people in Texas, with lower insurance coverage and more limited access to safety net programs for contraceptive care than in California, have lower use of preferred contraception. It has become urgent in states with abortion bans to support young people's access to their preferred methods.
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Anticoncepção , Anticoncepcionais , Preferência do Paciente , Adolescente , Adulto , Feminino , Humanos , Adulto Jovem , California , Política de Saúde , Cobertura do Seguro , Texas , Ensaios Clínicos Controlados Aleatórios como AssuntoRESUMO
CONTEXT: Abortion assistance funds constitute an important part of the healthcare safety net by covering some of abortion patients' out-of-pocket costs. Few studies have examined the other ways abortion assistance fund staff and volunteers support callers who need help obtaining care. METHODS: Between June and September 2020, we conducted in-depth interviews with 23 staff and volunteers at 11 local abortion assistance funds that helped Texans seeking abortion care following a March 2020 state executive order that prohibited most abortions. Interviewers explored respondents' experiences with callers whose appointments had been canceled or who traveled out of state and subsequent operational changes. We used both inductive and deductive codes in the thematic analysis. RESULTS: Abortion assistance fund staff and volunteers bridged callers' information gaps about the services and financial resources available and helped create plans to secure care that accounted for callers' specific needs. They provided emotional support so callers felt it was possible to overcome logistical hurdles to get an abortion, even if that required out-of-state travel. Respondents described greater collaboration between Texas-based abortion assistance funds and out-of-state organizations to support callers' more complex logistical needs and increased costs. Some callers who encountered multiple barriers to care, including interpersonal violence, were unable to obtain an abortion, even with additional supports. CONCLUSIONS: Local abortion assistance funds worked with Texas callers to co-create person-centered plans for care and expanded inter-organization collaborations. Initiatives that bolster local assistance funds' infrastructure and capacity will be needed as the abortion access landscape becomes further restricted and complex.
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OBJECTIVE: To evaluate how Texas health care professionals who care for patients experiencing medically complex pregnancies navigate abortion restrictions. METHODS: We conducted qualitative in-depth interviews with health care professionals across Texas who cared for patients with life-limiting fetal diagnoses or who had existing or developed health conditions that adversely affected pregnancy. We conducted the first round of interviews March-June 2021 and the second round of interviews January-May 2022 after the implementation of Texas Senate Bill 8 (SB8), which prohibited most abortions after detection of embryonic cardiac activity. We used inductive and deductive qualitative analysis to identify themes and changes in practice after the implementation of SB8. RESULTS: We conducted a total of 50 interviews: 25 before implementation of SB8 and 25 after the law's implementation. We interviewed 21 maternal-fetal medicine specialists, 19 obstetrician-gynecologists, eight physicians whose primary practice is the provision of abortion care, and two genetic counselors. Participants reported presenting their patients with information about health risks and outcomes of continued pregnancy in each policy period; however, counseling on these options was curtailed after implementation of SB8. Even in cases in which a patient's health and, in some cases, life would be compromised, narrow criteria for abortions at hospitals limited care before implementation of SB8, and criteria often became more stringent after implementation of SB8. Administrative approval processes and referrals for abortion delayed care and endangered patients' health, which worsened after in-state options were eliminated after implementation of SB8. Participants noted that patients with more limited resources who were unable to travel out of state often had to continue pregnancies, further increasing their risk of morbidity. CONCLUSION: Texas health care professionals' abilities to provide evidence-based abortion care to patients with medically complex pregnancies were constrained by institutional policies, and care options narrowed further after implementation of SB8. Abortion restrictions limit shared decision making, compromise patient care, and put pregnant people's health at risk.
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Aborto Induzido , Acessibilidade aos Serviços de Saúde , Gravidez , Feminino , Humanos , Texas , Aconselhamento , HospitaisRESUMO
OBJECTIVE: To evaluate the association between Medicaid insurance and fulfillment of postpartum permanent contraception requests. METHODS: We conducted a retrospective cohort study of 43,915 patients across four study sites in four states, of whom 3,013 (7.1%) had a documented contraceptive plan of permanent contraception at the time of postpartum discharge and either Medicaid insurance or private insurance. Our primary outcome was permanent contraception fulfillment before hospital discharge; we compared individuals with private insurance with individuals with Medicaid insurance. Secondary outcomes were permanent contraception fulfillment within 42 and 365 days of delivery, as well as the rate of subsequent pregnancy after nonfulfillment. Bivariable and multivariable logistic regression analyses were used. RESULTS: Patients with Medicaid insurance (1,096/2,076, 52.8%), compared with those with private insurance (663/937, 70.8%), were less likely to receive desired permanent contraception before hospital discharge (P≤.001). After adjustment for age, parity, weeks of gestation, mode of delivery, adequacy of prenatal care, race, ethnicity, marital status, and body mass index, private insurance status was associated with higher odds of fulfillment at discharge (adjusted odds ratio [aOR] 1.48, 95% CI 1.17-1.87) and 42 days (aOR 1.43, 95% CI 1.13-1.80) and 365 days (aOR 1.36, 95% CI 1.08-1.71) postpartum. Of the 980 patients with Medicaid insurance who did not receive postpartum permanent contraception, 42.2% had valid Medicaid sterilization consent forms at the time of delivery. CONCLUSION: Differences in fulfillment rates of postpartum permanent contraception are observable between patients with Medicaid insurance and patients with private insurance after adjustment for clinical and demographic factors. The disparities associated with the federally mandated Medicaid sterilization consent form and waiting period necessitate policy reassessment to promote reproductive autonomy and to ensure equity.
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Anticoncepção , Medicaid , Gravidez , Feminino , Estados Unidos , Humanos , Estudos Retrospectivos , Período Pós-Parto , Esterilização ReprodutivaRESUMO
OBJECTIVE: To assess abortion patients' self-judgment in a setting with antiabortion protestors. STUDY DESIGN: We analyzed data from a survey of 196 Mississippi abortion clients who interacted with antiabortion protestors, using ANOVA to compare feelings of self-judgment (measured on a 0-to-4 Likert-based scale) by religious identity. We assessed support for a law limiting protestor activity using a Χ2 test. RESULTS: The mean self-judgment score was 1.1 among respondents with no religious identity (n = 43), 1.4 among religious, not evangelical respondents (n = 95), and 1.5 among evangelical respondents (n = 58, p = 0.23). Most respondents (79%) supported a lawlimiting protestor activity. DISCUSSION: Overall, self-judgment was low and support for a law limiting protestor access was high.
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Aborto Induzido , Julgamento , Gravidez , Feminino , Humanos , Mississippi , Protestantismo , Inquéritos e QuestionáriosRESUMO
During the COVID-19 pandemic, existing and new abortion restrictions constrained people's access to abortion care. We assessed Texas abortion patients' out-of-state travel patterns before and during implementation of a state executive order that prohibited most abortions for 30 days in 2020. We received data on Texans who obtained abortions between February and May 2020 at 25 facilities in six nearby states. We estimated weekly trends in the number of out-of-state abortions related to the order using segmented regression models. We compared the distribution of out-of-state abortions by county-level economic deprivation and distance traveled. The number of Texas out-of-state abortions increased 14% the week after (versus before) the order was implemented (incidence rate ratio [IRR] = 1.14; 95% CI: 0.49, 2.63), and increased weekly while the order remained in effect (IRR = 1.64; 95% CI: 1.23, 2.18). Residents of the most economically disadvantaged counties accounted for 52% and 12% of out-of-state abortions before and during the order, respectively (p < 0.001). Before the order, 38% of Texans traveled ≥250 miles one way, whereas during the order 81% traveled ≥250 miles (p < 0.001). Texans' long-distance travel for out-of-state abortion care and the socioeconomic composition of those less likely to travel reflect potential burdens imposed by future abortion bans.
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Aborto Induzido , COVID-19 , Gravidez , Feminino , Humanos , Estados Unidos , Texas , Pandemias , Acessibilidade aos Serviços de Saúde , ViagemRESUMO
PURPOSE: Texas is one of 24 states that restricts minors' ability to obtain contraception without parental consent, unless they access confidential services at federally funded Title X clinics. This study explores Texas minors' reasons for and experiences seeking confidential contraception. METHODS: Between September 2020 and June 2021, we conducted in-depth phone interviews with 28 minors aged 15-17 years. Participants were recruited via the text line and Instagram account of an organization that helps young people navigate Texas' parental consent laws. Interview transcripts were coded and analyzed using inductive and deductive codes in our thematic analysis. RESULTS: Participants wanted to be proactive about preventing pregnancy by using more effective contraceptive methods but faced resistance from adults when they initiated conversations about sex and contraception or tried to obtain consent. In the absence of adult support, they turned to online and social media resources for information about types of contraception but encountered challenges finding accurate information about where to obtain methods in Texas without a parent. Only 10 participants were able to attend an appointment for contraception. Parents' increased monitoring of minors' activities during the COVID-19 pandemic, combined with transportation and appointment-scheduling barriers, made it difficult for minors to attend in-person visits, particularly if clinics were farther away. DISCUSSION: Minors in Texas faced a range of barriers to finding accurate information and obtaining confidential contraceptive services, which were exacerbated by the COVID-19 pandemic. Expanding options for accessible confidential contraception, along with repealing parental consent laws, would better support minors' reproductive autonomy.
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COVID-19 , Menores de Idade , Gravidez , Feminino , Adulto , Humanos , Adolescente , Texas , Pandemias , Anticoncepção , Consentimento dos PaisRESUMO
INTRODUCTION: After the onset of the COVID-19 pandemic, the use of family planning services decreased, but there are limited data on how safety net providers were affected. METHODS: Between November 2020 and March 2021, we conducted in-depth interviews with administrators at health departments, federally qualified health centers, and specialized family planning organizations across Texas about pandemic-related changes in family planning services. We analyzed interview transcripts using an inductive thematic approach. RESULTS: Administrators at the 19 participating organizations described pervasive service disruptions. Some organizations closed for 6-8 weeks at the pandemic's onset owing to safety uncertainties and difficulty interpreting Texas' March 2020 executive order prohibiting "nonessential" medical services; others later suspended services after staff exposures. Health departments and federally qualified health centers commonly decreased family planning services to focus on COVID-19 response, leaving specialized family planning organizations to absorb displaced reproductive health care clients. Some of the advantages of service delivery modifications-including telehealth, curbside and drive-through prescription pickup, and medication by mail-were difficult to realize; barriers included low reimbursement, necessary patient examinations, and clients' confidentiality concerns and lack of technological resources. CONCLUSIONS: Texas' diverse network of family planning organizations illustrated a range of responses to the pandemic, and organizations often focused on their core missions-public health, primary care, or family planning.
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COVID-19 , Serviços de Planejamento Familiar , Humanos , Texas/epidemiologia , Pandemias , COVID-19/epidemiologia , Pessoal AdministrativoRESUMO
OBJECTIVES: Assess preferences for and use of medication abortion in Texas after implementation of two policy changes: a 2013 state law restricting medication abortion and the FDA label change for mifepristone in 2016 nullifying some of this restriction. STUDY DESIGN: We analyzed surveys conducted in 2014 and 2018 with abortion patients at 10 Texas abortion facilities. We calculated the percentage of all respondents with an initial preference for medication abortion by survey year, and the type of abortion obtained or planned to obtain among those who were at <10 weeks of gestation. We used multivariable-adjusted mixed-effects Poisson regression models to assess factors associated with medication abortion preference and actual/planned use. RESULTS: Overall, 156 (41%) of 376 respondents in 2014 and 247 (55%) of 448 respondents in 2018 reported initial preference for medication abortion (Prevalence ratio [PR]: 1.28; 95% CI 1.03-1.59). Among those who were <10 weeks of gestation and initially preferred medication abortion, 39 of 124 (31%) obtained or were planning to obtain the method in 2014, compared with 188 of 223 (84%) in 2018 (PR: 2.65; 95% CI: 1.69-4.15). After multivariable adjustment, respondents who initially preferred medication abortion and were 7 to 9 weeks of gestation at the time of their ultrasonography (vs <7 weeks) were less likely to obtain or plan to obtain the method (PR: 0.69; 95% CI: 0.57-0.84). CONCLUSIONS: Abortion patients were more likely to prefer and obtain or plan to obtain their preferred medication abortion after legal restrictions in Texas were nullified. IMPLICATIONS: State policies can affect people's ability to obtain their preferred abortion method. Efforts to provide both abortion options whenever possible, and inform people where each can be obtained, remains an important component of person-centered care despite increasing state abortion restrictions and bans following the reversal of Roe v Wade.
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Aborto Induzido , Gravidez , Feminino , Humanos , Texas , Mifepristona/uso terapêutico , Inquéritos e QuestionáriosRESUMO
BACKGROUND: Telemedicine expanded rapidly during the COVID-19 pandemic, including for contraceptive services. Data are needed to understand whether young people can access telemedicine for contraception, especially in underserved populations. OBJECTIVE: To compare young people's perceived access to telemedicine visits for contraception during the COVID-19 pandemic by food and housing insecurity. DESIGN: Supplementary study to a cluster randomized controlled trial in 25 community colleges in California and Texas. Online surveys were administered May 2020 to April 2021. Mixed-effects logistic regression models with random effects for site were used to examine differences in access to contraception through telemedicine by food and housing insecurity status, controlling for key sociodemographic characteristics, including race/ethnicity, non-English primary language, health insurance status, and state of residence, and contraceptive method used. PARTICIPANTS: 1,414 individuals assigned female at birth aged 18-28. MAIN MEASURES: Survey measures were used to capture how difficult it would be for a participant to have a telemedicine visit (phone or video) for contraception. KEY RESULTS: Twenty-nine percent of participants were food insecure, and 15% were housing insecure. Nearly a quarter (24%) stated that it would be difficult to have a phone or video visit for contraception. After accounting for sociodemographic factors and type of method used, food insecure (adjusted odds ratio [aOR], 2.17; 95% confidence interval [CI], 1.62-2.91) and housing insecure (aOR, 1.62; 95% CI, 1.13-2.33) participants were significantly more likely to report that it would be difficult to use telemedicine for contraception during the pandemic. CONCLUSIONS: Underserved patients are those who could benefit most from the expansion of telemedicine services, yet our findings show that young people experiencing basic needs insecurity perceive the greatest difficulty accessing these services for essential reproductive care. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03519685.