Examining Temporal Trends in Documentation of Pregnancy Intentions in Family Planning Health Centers Using Electronic Health Records.

Objectives Few studies have examined the extent to which providers assess pregnancy intentions during clinical encounters. Our objective was to assess temporal trends in documentation of patient pregnancy intentions in electronic health records (EHR). Methods In this retrospective observational study using EHR data from 627,399 female patients visiting 214 family planning centers in 2012-2014, we assessed changes in the prevalence of pregnancy intention documentation with piecewise log-binomial regression models. We examined bivariate associations between patient/visit characteristics and pregnancy intention documentation in each year, and associations between patients' pregnancy intentions and contraceptive methods. Results The proportion of patients with a documented pregnancy intention increased sharply from the end of 2012 (42%) to the midpoint of 2013 (85%; adjusted quarterly prevalence ratio [APR] = 1.40, 95% CI 1.36-1.45). Thereafter, the rate of change slowed as documentation approached the maximum possible frequency (93%; APR = 1.01, 95% CI 1.00-1.02). Documentation varied by all patient/visit characteristics in 2012 and 2013; in 2014, there were no clinically significant differences. Among patients with a documented intention, 97% were not planning a pregnancy in the next year. Women not planning a pregnancy were more likely to use a most/moderately effective contraceptive method than those planning a pregnancy (73 vs. 35%, p < 0.0001). Conclusions for Practice Improvements in pregnancy intention documentation co-occurred with changes to EHR templates (e.g., placement of structured data fields) and with provider-focused initiatives promoting reproductive life planning. Patients' pregnancy intentions aligned with contraceptive use; however, these findings cannot address whether assessment of intentions affects contraceptive use.

Predictors of Human Papillomavirus Vaccine Completion Among Female and Male Vaccine Initiators in Family Planning Centers.

OBJECTIVES: We estimated human papillomavirus (HPV) vaccine series completion and examined predictors of completion among adolescents and young adults in a large family planning network. METHODS: Our retrospective cohort study of vaccine completion within 12 months and time to completion used electronic health record data from 119 Planned Parenthood health centers in 11 US states for 9648 patients who initiated HPV vaccination between January 2011 and January 2013. RESULTS: Among vaccine initiators, 29% completed the series within 12 months. Patients who were male, younger than 22 years, or non-Hispanic Black or who had public insurance were less likely to complete within 12 months and completed more slowly than their counterparts. Gender appeared to modify the effect of public versus private insurance on completion (adjusted hazard ratio = 0.76 for women and 0.95 for men; relative excess risk due to interaction = 0.41; 95% confidence interval = 0.09, 0.73). CONCLUSIONS: Completion was low yet similar to previous studies conducted in safety net settings.

Translating an Evidence-Based Behavioral Intervention for Women Living with HIV into Clinical Practice: The SMART/EST Women's Program.

BACKGROUND: The process of translating scientific findings into clinical and public health settings has only recently received priority attention within the scientific community. PURPOSE: Fueled by "Funding Opportunity Announcements" from the National Institutes of Health and Centers for Disease Control and Prevention, scientists have begun to explore the pathways to effectively "transfer" promising research accomplishments into effective and sustainable service programs within the health care delivery system. METHOD: Using Glasgow's RE-AIM (Reach, Effectiveness, Adoption, Implementation and Maintenance) model as a guide, this research team enrolled 428 socially disadvantaged, culturally diverse women living with HIV/AIDS to test the dissemination and implementation of an evidence-based behavioral intervention designed to improve and sustain the physical and emotional health of participants into the Community Health Center (CHC) setting when conducted by trained CHC staff. RESULTS: Findings demonstrate the ability of trained CHC staff group leaders to attain results equivalent or superior to those achieved when conducted by research staff on the three principal study outcomes: depression, medication adherence and HIV viral load. Four of five CHCs involved in the study also identified and successfully obtained funding to continue to run intervention groups, supporting the adoption and sustainability components of the translation model. CONCLUSION: This study confirmed (a) the "translatability" of the Stress Management And Relaxation Training/Emotional Supportive Therapy (SMART/EST) Women's Program, from academic to CHC settings in two geographic regions with high HIV prevalence among women, (b) the ability of local staff (using the "train the trainer" model) to successfully achieve program fidelity and clinical outcomes, and (c) the sustainability the program beyond the auspices of research support, through supportive CHC leadership securing continued program funding.

An assessment of clinical outcomes of medication abortion without pretreatment ultrasonography in Planned Parenthood, United States, 2020-2021.

OBJECTIVES: Routine ultrasound before medication abortion (MAB) may create an impediment to expanding abortion access. This study examines clinical outcomes of MAB without pretreatment ultrasound evaluation at Planned Parenthood health centers in multiple states. STUDY DESIGN: We conducted a secondary analysis of data from 23 US-based Planned Parenthood affiliates that provided MAB without pretreatment ultrasound for eligible patients from March 2020 to December 2021. Affiliates aggregated electronic health record data from MABs at ≤77 days gestation (based on self-report of last menstrual period) without a pretreatment ultrasound (N = 18,041). Among MABs with known outcomes (N = 9821), we calculated the incidence rates and 95% confidence intervals (CI) for completed abortion, ongoing pregnancy, subsequent procedure, emergency department/hospital visits associated with MAB, ectopic pregnancies, and gestational duration greater than 77 days. RESULTS: Among MABs with known outcomes, 96.3% had a complete abortion (95% CI = 95.9%-96.7%), and 2.0% had an ongoing pregnancy (95% CI = 1.7%-2.3%). Four percent had a subsequent procedure (95% CI = 3.6%-4.4%), and 2.3% had a documented emergency department/hospital visit (95% CI = 2.0%-2.6%). Less than 1% had a confirmed ectopic pregnancy (0.15%, 95% CI = 0.09%-0.25%) and had a gestational duration later identified to be greater than 77 days (0.13%, 95% CI = 0.05%-0.29%). CONCLUSIONS: Our calculated incidence rates of clinical outcomes align with rates from the previous literature on MAB and from the emerging literature on MAB without pretreatment ultrasonography. Findings from this analysis suggest that MAB without pretreatment ultrasound is safe and effective for eligible patients. IMPLICATIONS: This large US study found that medication abortion without pretreatment ultrasonography results in similar clinical outcomes to prepandemic models that include pretreatment ultrasonography. Medication abortion without a pretreatment ultrasound may be adopted by abortion providers seeking to expand options for their patients as access to abortion continues to erode.

Introduction of telemedicine for medication abortion: Changes in service delivery patterns in two U.S. states.

OBJECTIVE(S): Telemedicine for medication abortion (teleMAB) is safe and effective, yet little is known about how its introduction affects service delivery. We assessed changes in service delivery patterns 1 year after introducing teleMAB at Planned Parenthood in 2 U.S. states. STUDY DESIGN: Retrospective records analysis using electronic health record data from Planned Parenthood health centers in Montana and Nevada from 2015 to 2018. We included all patients receiving medication or aspiration abortion in the year before and after introducing site-to-site teleMAB. Outcomes included: the proportion of medication abortions (vs. aspiration); gestational age at abortion; time to appointment; and distance traveled. We compared outcomes pre- and postimplementation using χ2, t tests, and Mann-Whitney U tests. RESULTS: We analyzed data for 3,038 abortions: 1,314 pre- and 1,724 postimplementation. In Montana, the proportion of medication abortions increased postimplementation (60% vs. 65%, p = 0.04). Mean gestational age was similar: 58 versus 57 days (p = 0.35). Mean time to appointment decreased (14 vs. 12 days, p < 0.0001), as did one-way distance traveled by patients (134 vs. 115 miles, p = 0.03). In Nevada, where Planned Parenthood only provided medication abortion, total medication abortions increased (461 vs. 735). Mean gestational age remained stable (51 vs. 51 days, p = 0.33), as did time to appointment (8 vs. 8 days, p = 0.76). Mean one-way distance traveled was 47 miles in the preperiod versus 34 miles in the postperiod (p = 0.22). CONCLUSION(S): Medication abortion increased after the introduction of telemedicine in both states, though we cannot account for abortions performed by other providers. Telemedicine has the potential to improve access to medication abortion. IMPLICATIONS: Telemedicine has the potential to improve or maintain access to medication abortion and should be taken to scale where feasible. Continued efforts are needed to mitigate or reverse policy restrictions on telemedicine for medication abortion.

Contraceptive counseling practices and patient experience: Results from a cluster randomized controlled trial at Planned Parenthood.

OBJECTIVES: Systematic reviews of contraceptive counseling interventions have shown inconsistent impact on patient outcomes. The current study assessed the effects of an evidence-informed contraceptive counseling staff training intervention on patient experience, contraceptive selection, and behavior over three months of follow-up. STUDY DESIGN: We randomly assigned 10 Planned Parenthood health centers in the Southeastern US to intervention (staff received contraceptive counseling training) and control (usual counseling) groups. From December 2016-June 2017, patients completed surveys immediately post visit (n = 756) and one and three months after. We compared differences in patients' counseling experience (e.g., number of evidence-informed practices experienced, satisfaction with counseling), contraceptive selection, and behavior (e.g., method discontinuation, accurate pill use, condom use) between study groups using mixed effect models with health center specified as a random effect. RESULTS: Seven hundred and fifty-six participants completed the baseline survey; 579 (77%) completed one or both follow-up surveys. The intervention group was more likely to report experiencing all evidence-informed counseling practices (adj. Prevalence Ratio [aPR] = 2.27, 95% CI 1.27, 4.04) with less variation in the number of practices and higher satisfaction with their counseling than the control group (p < 0.01). We found no sustained differences in contraceptive behaviors at both one- and three-month follow-up. CONCLUSIONS: We found immediate positive effects of the intervention on patients' perceptions of their counseling experience and no differences in changes in contraceptive behavior over time between the study groups. IMPLICATIONS: Evidence-based strategies to improve the quality of contraceptive care and subsequent outcomes, while centering patients' needs and preferences, are needed. The contraceptive counseling intervention offers a tool for increasing consistency in contraceptive counseling practices across health centers and improving patient satisfaction.

Perinatal Depressive Symptom Trajectories Among Adolescent Women in New York City.

PURPOSE: The aim of the study was to estimate distinct trajectories of depressive symptoms among adolescent women across the perinatal period. METHODS: Using longitudinal depressive symptom data (Center for Epidemiologic Studies Depression Scale) from control participants in the Centering Pregnancy Plus Project (2008-2012), we conducted group-based trajectory modeling to identify depressive symptomatology trajectories from early pregnancy to 1-year postpartum among 623 adolescent women in New York City. We examined associations between sociodemographic, psychosocial, and pregnancy characteristics and the outcome, depressive symptom trajectories. RESULTS: We identified three distinct trajectory patterns: stable low or no depressive symptoms (58%), moderate depressive symptoms declining over time (32%), and chronically high depressive symptoms (11%). Women with chronically high symptoms reported higher levels of pregnancy distress and social conflict and lower perceived quality of social support than other women. CONCLUSIONS: This study found heterogeneity in perinatal depressive symptom trajectories and identified a group with chronically high symptoms that might be detected during prenatal care. Importantly, we did not identify a trajectory group with new-onset high depressive symptoms postpartum. Findings have important implications for screening and early treatment.

Medication Abortion Provided Through Telemedicine in Four U.S. States.

OBJECTIVE: To assess outcomes of medication abortion provided through telemedicine compared with standard medication abortion at Planned Parenthood health centers in four U.S. states. METHODS: In this retrospective cohort study, we analyzed electronic health records for patients receiving telemedicine compared with standard medication abortion at 26 health centers in Alaska, Idaho, Nevada, and Washington from April 2017 to March 2018. All patients had on-site ultrasound scans, laboratory testing, and counseling and provided informed consent before meeting with the clinician. Telemedicine patients met with a clinician by secure videoconference platform; standard patients met with a clinician in person. We also reviewed adverse event reports submitted during this period. Study outcomes included ongoing pregnancy, receipt of or referral for aspiration procedure, and clinically significant adverse events. To compare outcomes between the telemedicine and standard groups, we performed logistic regression accounting for gestational age and health center clustering. RESULTS: A total of 5,952 patients underwent medication abortion (738 telemedicine and 5,214 standard). Mean gestational age was 50.4 days for telemedicine patients compared with 48.9 days for standard patients (prevalence ratio 1.02; 95% CI 1.00-1.03). We had outcome data for 4,456 (74.9%) patients; follow-up within 45 days of abortion was lower among telemedicine patients (60.3%) than standard patients (76.9%) (prevalence ratio 0.83; 95% CI 0.78-0.88). Among patients with follow-up data, ongoing pregnancy was less common among telemedicine patients (2/445, 0.5%) than standard patients (71/4,011, 1.8%) (adjusted odds ratio [OR] 0.23; 95% CI 0.14-0.39). Aspiration procedures were less common among telemedicine patients (6/445, 1.4%) than standard patients (182/4,011, 4.5%) (adjusted OR 0.28; 95% CI 0.17-0.46). Fewer than 1% of patients in each group reported clinically significant adverse events. No deaths were reported. CONCLUSION: Findings from this study conducted across geographically diverse settings support existing evidence that outcomes for medication abortion provided through telemedicine are comparable with standard provision of medication abortion. Differences in observed outcomes may be due to differential follow-up between groups.

A model for surveillance of methicillin-resistant Staphylococcus aureus.

It is well recognized that methicillin-resistant Staphylococcus aureus (MRSA) has become a community pathogen. Several key differences between community-associated and hospital-associated MRSA strains exist, including distinct methicillin resistance genes and genetic backgrounds and differing susceptibility to antibiotics. Recent studies have demonstrated that typical hospital and community strains easily move between hospital and community environments. Despite evidence of MRSA's expanding reach in the community, the best methods for population-level detection and containment have not been established. In an effort to determine effective methods for monitoring the spread of MRSA, we reviewed the literature on hospital-associated and community-associated MRSA (CA-MRSA) in the community and proposed a model for enhanced surveillance. By linking epidemiologic and molecular techniques within a surveillance system that coordinates activities in the community and health-care setting, scientists and public health officials can begin to measure the true extent of CA-MRSA in communities and hospitals.

Increased 1-year continuation of DMPA among women randomized to self-administration: results from a randomized controlled trial at Planned Parenthood.

OBJECTIVES: Self-administration of subcutaneous depot medroxyprogesterone acetate (DMPA-sc) is feasible, acceptable, and effective. Our objective was to compare one-year continuation of DMPA-sc between women randomized to self-administration versus clinic administration. STUDY DESIGN: We randomized 401 females ages 15-44 requesting DMPA at clinics in Texas and New Jersey to self-administration or clinic administration in a 1:1 allocation. Clinic staff taught participants randomized to self-administration to self-inject and observed the first injection; participants received instructions, a sharps container, and three doses for home use. Participants randomized to clinic administration received usual care. All participants received DMPA-sc at no cost and injection reminders via text message or email. We conducted follow-up surveys at six and 12 months. RESULTS: Three hundred thirty-six participants (84%) completed the 12-month survey; 316 completed both follow-up surveys (an 80% response rate excluding eight withdrawals). Participants ranged in age from 16-44. One-year DMPA continuous use was 69% in the self-administration group and 54% in the clinic group (p=.005). There were three self-reported pregnancies during the study period, all occurred in the clinic group; all three women had discontinued DMPA and one reported her pregnancy as intended. Among the self-administration group, 97% reported that self-administration was very or somewhat easy; 87% would recommend self-administration of DMPA-sc to a friend. Among the clinic group, 52% reported interest in self-administration in the future. Satisfaction was similar between groups. No serious adverse events were reported. CONCLUSIONS: DMPA self-administration improves contraceptive continuation and is a feasible and acceptable option for women and adolescents. IMPLICATIONS: Self-administration of subcutaneous DMPA can improve contraceptive access, autonomy, and continuation, and is a feasible and acceptable option for women and adolescents. It should be made widely available as an option for women and adolescents.

Attitudes toward comparative effectiveness research and patient engagement among reproductive health clinicians.

AIM: To assess reproductive health clinicians' knowledge of and attitudes toward comparative effectiveness research (CER), patient-centered outcomes research (PCOR) and patient engagement in research. MATERIALS & METHODS: Web-based survey of reproductive health clinicians. RESULTS: Among 103 responding clinicians, familiarity with CER and PCOR was moderate (35 and 44%, respectively). Once definitions were provided, most respondents agreed with the potential positive impacts of CER and patient engagement (65-87%), the importance of PCOR (95-99%) and that their patients might be interested in engaging in research as more than subjects (93%). CONCLUSION: We found positive attitudes toward PCOR and CER, and a range of experiences with patient engagement in research. There may be untapped potential for PCOR and CER in the reproductive health field.

Maternal nativity and sleep-related infant injury deaths in New York City.

BACKGROUND: Half of all births in New York City are to women born outside of the United States whose infant care practices may differ from official recommendations from the American Academy of Pediatrics. These infants have an overall lower infant mortality rate than those of their US-born counterparts. AIMS: The aims of this study were to examine sleep-related infant injury death, a leading cause of infant mortality, and its risk factors among infants of US-born and foreign-born women in a large, diverse urban area. STUDY DESIGN: Data for 344 infant death cases from medical examiner and vital statistics records were analyzed. Rate ratios and 95% CIs, calculated with Poisson regression models, were used to quantify differences in death rates by maternal and infant characteristics. Bivariate and logistic regression analyses were used to examine differences within the sample of sleep-related infant injury deaths. OUTCOME MEASURES: The outcome measures were rate of sleep-related injury death, and behavioral risk factors associated with these deaths: unsafe sleep positioning, bed-sharing, and excess bedding. RESULTS: US-born mothers had a sleep-related infant injury death rate that was over three times that of foreign-born mothers, even when controlling for maternal race/ethnicity, education, and age. However, adverse sleep-related practices were not consistently more prevalent among US-born infants in the sample of deaths, even when controlling for those same demographic factors. CONCLUSIONS: The higher rate of sleep-related infant injury death among infants of US-born mothers may be explained by more complex socio-demographic factors, or factors outside of infant sleep practices.

Weight and body mass index among female contraceptive clients.

OBJECTIVES: As obesity may affect the efficacy of some contraceptives, we examined weight, body mass index (BMI) and prevalence of obesity among female contraceptive clients at 231 U.S. health centers. A secondary aim was to analyze differences in contraceptive method use by obesity status. STUDY DESIGN: Cross-sectional study using de-identified electronic health record data from family planning centers. We analyzed contraceptive visits made by 147,336 females aged 15-44 years in 2013. RESULTS: A total of 46.1% of clients had BMI ≥25. Mean body weight was 154.4 lb (S.D.=41.9); mean BMI was 26.1 (S.D.=6.6). A total of 40% had BMI ≥26, when levonorgestrel emergency contraception may become less effective. Obese clients had higher odds of using a tier 1 or tier 3 contraceptive method and had lower odds of using a tier 2 or hormonal method than non-obese clients. CONCLUSIONS: About half of contraceptive clients would be categorized as overweight or obese. Contraceptive method choices differed by obesity status. IMPLICATIONS: About half of contraceptive clients in this study population were overweight or obese. Contraceptive method choices differed by obesity status. All women - regardless of body size - should receive unbiased, evidence-based counseling on the full range of contraceptive options so that they can make informed choices.

Differences in contraceptive use between family planning providers and the U.S. population: results of a nationwide survey.

OBJECTIVES: To describe contraceptive use among U.S. female family planning providers and to compare their contraceptive choices to the general population. STUDY DESIGN: We surveyed a convenience sample of female family planning providers ages 25-44 years, including physicians and advanced practice clinicians, via an internet-based survey from April to May 2013. Family planning providers were compared to female respondents ages 25-44 years from the 2011-2013 National Survey of Family Growth. RESULTS: A total of 488 responses were eligible for analysis; 331 respondents (67.8%) were using a contraceptive method. Providers' contraceptive use differed markedly from that of the general population, with providers significantly more likely to use intrauterine contraception, an implant, and the vaginal ring. Providers were significantly less likely to use female sterilization and condoms. There were no significant differences between providers and the general population in use of partner vasectomy or the pill. Long-acting reversible contraception (LARC) use was significantly higher among providers than in the general population (41.7% vs. 12.1%, p<.001). These results were consistent when stratifying by variables including self-identified race/ethnicity and educational level. CONCLUSIONS: The contraceptive choices of this sample of female family planning providers differed significantly from the general population. These findings have implications for clinical practice, patient education, and health policy. IMPLICATIONS: Family planning providers report higher use of LARC than the general population. This may reflect differences in preferences and access. Providers might consider sharing these findings with patients, while maintaining patient choice and autonomy.

Translation of a comprehensive health behavior intervention for women living with HIV: the SMART/EST Women's Program.

Translation of behavioral interventions into community settings for people living with HIV/AIDS can decrease the risk of comorbid conditions. This study was designed to determine whether a multiple health behavior intervention for women with HIV/AIDS could be effectively translated into community health centers (CHCs), delivered by CHC primary care staff. Health Resources and Services Administration-supported CHCs in Miami, FL, and the New York metropolitan area participated. Six health behavior domains were assessed at baseline, 6 months, and 12 months post-intervention: nutrition, physical activity, sexual risk behavior, alcohol use, drug use, and tobacco use. Behavioral outcomes were compared between research staff-led and CHC staff-led intervention groups. Research staff and CHC staff outcomes were similar for the majority of outcomes. Results indicate that complex, multicomponent behavioral interventions can be translated into community-based settings with existing CHC staff and can produce clinical effects similar to those achieved by research staff.

Multi-locus sequence typing of enteroaggregative Escherichia coli isolates from Nigerian children uncovers multiple lineages.

BACKGROUND: Enteroaggregative Escherichia coli (EAEC) are defined by their stacked-brick adherence pattern to human epithelial cells. There is no all-encompassing genetic marker for EAEC. The category is commonly implicated in diarrhea but research is hampered by perplexing heterogeneity. METHODOLOGY/PRINCIPAL FINDINGS: To identify key EAEC lineages, we applied multilocus sequence typing to 126 E. coli isolates from a Nigerian case-control study that showed aggregative adherence in the HEp-2 adherence assay, and 24 other EAEC strains from diverse locations. EAEC largely belonged to the A, B1 and D phylogenetic groups and only 7 (4.6%) isolates were in the B2 cluster. As many as 96 sequence types (STs) were identified but 60 (40%) of the EAEC strains belong to or are double locus variants of STs 10, 31, and 394. The remainder did not belong to predominant complexes. The most common ST complex, with predicted ancestor ST10, included 32 (21.3%) of the isolates. Significant age-related distribution suggests that weaned children in Nigeria are at risk for diarrhea from of ST10-complex EAEC. Phylogenetic group D EAEC strains, predominantly from ST31- and ST394 complexes, represented 38 (25.3%) of all isolates, include genome-sequenced strain 042, and possessed conserved chromosomal loci. CONCLUSIONS/SIGNIFICANCE: We have developed a molecular phylogenetic framework, which demonstrates that although grouped by a shared phenotype, the category of 'EAEC' encompasses multiple pathogenic lineages. Principal among isolates from Nigeria were ST10-complex EAEC that were associated with diarrhea in children over one year and ECOR D strains that share horizontally acquired loci.