Permanent Sterilization in Nulliparous Patients: Is Legislative Anxiety an Indication for Surgery?

AbstractThe Supreme Court's Dobbs v. Jackson Women's Health Organization decision, first leaked to the public on 2 May 2022 and officially released on 24 June 2022, overturned Roe v. Wade and thereby determined that abortion is no longer a federally protected right under the Constitution. Instead, the decision gives individual states the right to regulate abortion. Since the Dobbs decision first leaked, our institution has received numerous requests for permanent contraception from individuals stating that their motivation to pursue permanent contraception was influenced by the Dobbs decision and concerns about their reproductive autonomy. Discussions with patients seeking permanent contraception since the Supreme Court's leaked decision have led us to ask ourselves, is legislative anxiety an indication for surgery? This article presents a case series consisting of a convenience sample of 17 young, nulliparous individuals who sought out permanent contraception in the six months following the leak of the Dobbs decision. Healthcare professionals often feel discomfort in offering permanent contraception to young and nulliparous individuals. Accordingly, we discuss pertinent legal issues, review relevant ethical considerations, and offer a framework for these discussions intended to empower the consulting healthcare professional to center the bodily autonomy of every patient regardless of age, parity, or indication for permanent contraception.

Gaps in patient-physician communication at the time of malignant bowel obstruction from recurrent gynecologic cancer: a qualitative study.

PURPOSE: We sought to investigate the patient and physician approaches to malignant bowel obstruction (MBO) due to recurrent gynecologic cancer by (1) comparing patient and physician expectations and priorities during a new MBO diagnosis, and (2) highlighting factors that facilitate patient-doctor communication. METHODS: Patients were interviewed about their experience during an admission for MBO, and physicians were interviewed about their general approach towards MBO. Interviews were analyzed for themes using QDAMiner qualitative analysis software. The analysis utilized the framework analysis and used both predetermined themes and those that emerged from the data. RESULTS: We interviewed 14 patients admitted with MBO from recurrent gynecologic cancer and 15 gynecologic oncologists. We found differences between patients and physicians regarding plans for next chemotherapy treatments, foremost priorities, communication styles, and need for end-of-life discussions. Both patients and physicians felt that patient-physician communication was improved in situations of trust, understanding patient preferences, corroboration of information, and increased time spent with patients during and before the MBO. CONCLUSION: Gaps in patient-physician communication could be targeted to improve the patient experience and physician counseling during a difficult diagnosis. Our findings emphasize a need for patient-physician discussions to focus on expectations for future cancer-directed treatments, support for patients at home with home health or hospice level support in line with their wishes, and acknowledgement of uncertainty while providing direct information about the MBO diagnosis.

Educational Pelvic Examinations Under Anesthesia: Recommendations for Clinicians and Learners.

Professional directives are unwavering: educational intimate exams should only ever occur with patients' explicit consent. This article describes the current clinical, educational, and ethical landscape of educational pelvic examinations under anesthesia, underscores the imperative that these exams only ever occur with patients' explicit consent, and offers accessible modifications to students' involvement in these exams.

A Novel Lay Health Worker Training to Help Women Engage in Postabortion Contraception and Well-Woman Care.

Young women, low-income women, and women of color make up a disproportionate share of abortion patients and experience higher rates of unintended pregnancy, maternal morbidity and mortality, and infant mortality. Furthermore, these individuals are also less likely to have access to preventive gynecologic care. Whereas lay health worker interventions have been developed to help link individuals to care in other fields, the use of such interventions to link individuals to preventive care after abortion is novel. This article describes a training protocol and curriculum that provided nonmedically trained individuals with knowledge, skills, and competency to conduct a behavioral theory-based counseling intervention to help individuals achieve self-identified goals regarding obtaining postabortion reproductive health care and contraception. When piloted with 60 patients presenting for abortion who lacked a regular health care provider and desired to delay pregnancy for at least 6 months, participants found the lay health worker skills and the counseling session highly acceptable. Specifically, participants reported feeling comfortable speaking to lay health workers about contraception and reproductive health care. These findings indicate that lay health worker interventions may present an important opportunity to help individuals address their postabortion preventive and contraceptive health care needs.

Factors Shaping Women's Pre-abortion Communication with Members of Their Social Network.

To understand women's pre-abortion conversations with members of their social network about their abortion decision. Semi-structured interviews were conducted with women presenting for first-trimester surgical abortion at a high volume, hospital-based abortion clinic. Women were asked their reasons for discussing or not discussing abortion and responses received after disclosing their abortion decision. Interviews were transcribed and computer-assisted content analysis was performed. Salient themes are presented. Thirty women who obtained an abortion were interviewed. All but three spoke to at least one member of their social network about their abortion decision making. However, women were very selective about whom they spoke to regarding this decision. Reasons not to discuss their abortion decision included: concerns about judgment, desiring to maintain privacy, and certainty about their decision. Reasons to discuss their abortion decision included: seeking information about the procedure, needing guidance about their decision, wanting support for their decision to proceed with abortion. While many were concerned about being judged, most women who spoke about their decision experienced a positive response. Though most women in this study had at least one person to turn to for assistance with abortion decision making, many participants avoided confiding in some or all members of their social network about their abortion decision due to concerns of judgment and stigma.

Evaluation of ethics education in obstetrics and gynecology residency programs.

OBJECTIVE: The objective of the study was to assess the current status of ethics education in obstetrics-gynecology residency programs. STUDY DESIGN: A cross-sectional, web-based survey was designed in conjunction with a professional survey laboratory at the University of Chicago. The survey was piloted with a convenience sample of clinical medical ethics fellows to assess question content and clarity. The survey was deployed by e-mail to all obstetrics-gynecology residency program directors. Descriptive statistics were used to analyze participant responses. The University of Chicago's Institutional Review Board deemed this study exempt from institutional review board formal review. RESULTS: Of 242 eligible obstetrics-gynecology residency program directors, 118 (49%) completed the survey. Most respondents were from university-based programs (n = 78, 66%) that were not religiously affiliated (n = 98, 83%) and trained 4-6 residents per postgraduate year (n = 64, 70%). Although 50% of program directors (n = 60) reported having ethics as part of their core curriculum, most programs teach ethics in an unstructured manner. Fifty-seven percent of respondents (n = 66) stated their program dedicated 5 or fewer hours per year to ethics. The majority of program directors (n = 80, 73%) responded they would like more to a lot more ethics education and believed that ethics education should be required (n = 93, 85%) for residents to complete their training. Respondents identified that crowding in the curriculum was a significant barrier to increased ethics training (n = 50, 45%) and two-thirds (n = 74, 67%) reported a lack of faculty expertise as a moderate barrier to providing ethics education in the residency curriculum. CONCLUSION: This study found that a lack of structured curricula, inadequate faculty expertise, and limited time were important barriers for ethics education in obstetrics-gynecology programs across the nation. Despite these existing challenges, program directors have a strong interest in increasing ethics education in residency training. Therefore, additional resources are needed to assist program directors in enhancing resident ethics education.

Doula support during first-trimester surgical abortion: a randomized controlled trial.

OBJECTIVE: The objective of the study was to evaluate the impact of doula support on first-trimester abortion care. STUDY DESIGN: Women were randomized to receive doula support or routine care during first-trimester surgical abortion. We examined the effect of doula support on pain during abortion using a 100 mm visual analog scale. The study had the statistical power to detect a 20% difference in mean pain scores. Secondary measures included satisfaction, procedure duration, and patient recommendations regarding doula support. RESULTS: Two hundred fourteen women completed the study: 106 received doula support, and 108 received routine care. The groups did not differ regarding demographics, gestational age, or medical history. Pain scores in the doula and control groups did not differ at speculum insertion (38.6 [±26.3 mm] vs 43.6 mm [±25.9 mm], P = .18) or procedure completion (68.2 [±28.0 mm] vs 70.6 mm [±23.5 mm], P = .52). Procedure duration (3.39 [±2.83 min] vs 3.18 min [±2.36 min], P = .55) and patient satisfaction (75.2 [±28.6 mm] vs 74.6 mm [±27.4 mm], P = .89) did not differ between the doula and control groups. Among women who received doula support, 96.2% recommended routine doula support for abortion and 60.4% indicated interest in training as doulas. Among women who did not receive doula support, 71.6% of women would have wanted it. Additional clinical staff was needed to provide support for 2.9% of women in the doula group and 14.7% of controls (P < .01). CONCLUSION: Although doula support did not have a measurable effect on pain or satisfaction, women overwhelmingly recommended it for routine care. Women receiving doula support were less likely to require additional clinic support resources. Doula support therefore may address patient psychosocial needs.

Digital media and sexually transmitted infections.

PURPOSE OF REVIEW: Digital media, including the Internet, social networking sites, text messaging, and mobile applications, are ubiquitous among adolescents and young adults. These platforms enable users to obtain important information on a multitude of health topics, they may facilitate risk-taking behaviors, and they can be key components of health interventions. The purpose of this article is to review the recent literature on digital media and sexually transmitted infections, discussing their role in potentiating and reducing risk. RECENT FINDINGS: This review demonstrates adolescents' use of digital media to gather information on health topics and discusses significant privacy concerns regarding using media to explore sexual health information. Although several studies demonstrate an association between social media and increased sexual risk-taking behaviors, this relationship is not fully understood. Digital media-based interventions are increasingly being developed to either reduce risk or improve management of sexually transmitted infections. SUMMARY: As greater numbers of adolescents use digital media, the potential for these platforms to influence sexual risk-taking behaviors is significant. Additional research is needed to better understand the impact of digital media on sexually transmitted infection risk and to develop social media-based interventions to improve sexually transmitted infection outcomes.

Cervical intraepithelial neoplasia and cancer in women 35 years and older.

OBJECTIVE: To evaluate the distribution of abnormal cytohistopathology among low-income women 35 years and older compared with women younger than 35 years. MATERIALS AND METHODS: This was a retrospective analysis of the 896 women who presented to the dysplasia clinic at an urban, public, tertiary care hospital with abnormal cervical cytology from September 23, 2008, to September 23, 2010. Statistical comparisons were made using t, χ(2), and Wilcoxon rank sum tests. RESULTS: Of the 896 patients, 460 (51%) were aged 35 years or older. Among the women 35 years and older, 56% had negative/benign histologic findings compared with 45% in women younger than 35 years. Conversely, women 35 years and older had lower rates of cervical intraepithelial neoplasia 1 (14%) than women younger than 35 years (30%). However, the prevalence of cancer diagnosis, per colposcopy, increased significantly with age, affecting 6% of women aged 50 years or older, 2% of women aged 35 to 49 years, and 1% of women younger than 35 years (p = .0008). CONCLUSIONS: Women older than 35 years with abnormal cytology demonstrated increased severity of cervical intraepithelial neoplasia on histology compared with younger women. Although women younger than 35 years were more likely to have transient human papillomavirus infections, a very high prevalence of severe cervical intraepithelial neoplasia and cancer was identified among women aged 35 years and older. Careful evaluation and follow-up must be performed for this group of women who may have previously been considered by some clinicians to be low risk on the basis of their age.

Implications of the Law on Reproductive and Sexual Health.

The United States has a longstanding history of using laws to define the scope of government involvement in controlling personal matters related to sex and sexuality. Although the government serves a valuable role in protecting and promoting public health, sexual and reproductive health is unduly impacted by social stigma in ways that other fields of medicine are not. Consequently, this care is often singled out by legislation that limits rather than protects this care. Health care professionals are uniquely positioned to advocate for legal protection of the patient-provider relationship and for access to essential health care, including abortion, contraception, and gender-affirming care.

Pelvic examination under anesthesia by learners at the time of abortion: Who accepts and who declines?

OBJECTIVES: This study aimed to assess the prevalence of and factors correlated with accepting a pelvic examination under anesthesia (EUA) by learners at the time of surgical abortion. STUDY DESIGN: Retrospective chart review assessing the prevalence of and comparing factors associated with accepting EUA by learners at the time of abortion. RESULTS: Most (88%) of the 274 patients accepted EUA by learners. Declining was associated with prior intimate partner violence. CONCLUSIONS: Most patients accept EUA by learners at the time of abortion. IMPLICATIONS: In adhering to fundamental principles of medical ethics, professional guidelines, and legal mandates, consent prior to pelvic EUA by learners should be obtained universally.

Duration of Induction of Labor for Second-Trimester Medication Abortion and Adverse Outcomes.

OBJECTIVE: To evaluate the relationship between duration of labor during second-trimester medication abortion and adverse outcomes. METHODS: We conducted a retrospective cohort study including all individuals with a singleton gestation undergoing second-trimester medication abortion without evidence of advanced cervical dilation, rupture of membranes, or preterm labor at four centers. The primary exposure was duration of labor (ie, hours spent from receiving misoprostol to fetal expulsion). The primary outcome was composite morbidity, defined as uterine rupture, need for blood transfusion, clinical chorioamnionitis, intensive care unit admission, or need for readmission. We performed bivariate and multivariate negative binomial analyses. A post hoc subgroup analysis was performed to assess for the risk of the primary outcome by gestational age. We performed tests of homogeneity based on history of uterine scarring and parity. RESULTS: Six hundred eighty-one individuals were included. The median duration of labor was 11 hours (interquartile range 8-17 hours). One hundred thirty-one (19.2%) experienced the primary outcome. When duration of labor was evaluated continuously, a longer duration of labor was associated with an increased frequency of morbidity (adjusted ß=0.68, 95% CI, 0.32-1.04). When duration of labor was evaluated categorically, those experiencing the highest quartile of duration (ie, 17 hours or more) had a statistically higher risk for experiencing morbidity compared with individuals in all other quartiles (adjusted relative risk 1.99, 95% CI, 1.34-2.96). When we focused on components of the composite outcome, clinical chorioamnionitis was significantly different between those experiencing a longer duration and those experiencing a shorter duration of labor (26.2% vs 10.6%, P<.001). On subgroup analysis, gestational age was not associated with the risk of composite morbidity. Tests of homogeneity demonstrated no significant difference in the risk for morbidity among individuals with a history of uterine scarring or based on parity. CONCLUSION: Duration of labor was independently associated with risks for adverse maternal outcomes during second-trimester medication abortion, specifically clinical chorioamnionitis.

State-Level Analysis of Intimate Partner Violence, Abortion Access, and Peripartum Homicide: Call for Screening and Violence Interventions for Pregnant Patients.

BACKGROUND: Despite representing 4% of the global population, the US has the fifth highest number of intentional homicides in the world. Peripartum people represent a unique and vulnerable subset of homicide victims. This study aimed to understand the risk factors for peripartum homicide. STUDY DESIGN: We used data from the 2018 to 2020 National Violent Death Reporting System to compare homicide rates of peripartum and nonperipartum people capable of becoming pregnant (12 to 50 years of age). Peripartum was defined as currently pregnant or within 1-year postpartum. We additionally compared state-level peripartum homicide rates between states categorized as restrictive, neutral, or protective of abortion. Pearson's chi-square and Wilcoxon rank-sum tests were used. RESULTS: There were 496 peripartum compared with 8,644 nonperipartum homicide victims. The peripartum group was younger (27.4 ± 71 vs 33.0 ± 9.6, p < 0.001). Intimate partner violence causing the homicide was more common in the peripartum group (39.9% vs 26.4%, p < 0.001). Firearms were used in 63.4% of homicides among the peripartum group compared with 49.5% in the comparison (p < 0.001). A significant difference was observed in peripartum homicide between states based on policies regarding abortion access (protective 0.37, neutral 0.45, restrictive 0.64; p < 0.01); the same trend was not seen with male homicides. CONCLUSIONS: Compared with nonperipartum peers, peripartum people are at increased risk for homicide due to intimate partner violence, specifically due to firearm violence. Increasing rates of peripartum homicide occur in states with policies that are restrictive to abortion access. There is a dire need for universal screening and interventions for peripartum patients. Research and policies to reduce violence against pregnant people must also consider the important role that abortion access plays in protecting safety.

Consent for Examinations Under Anesthesia With Learners at the Time of Abortion: Physician Perspectives.

INTRODUCTION: Although obtaining specific consent for examinations under anesthesia with learners is recommended by major professional organizations and mandated by many state laws and institutions, it is not practiced universally. We sought to investigate physicians' experiences using a formalized process to obtain consent from patients presenting for surgical abortions under anesthesia for pelvic examinations with learners. METHODS: Semistructured qualitative interviews were conducted with residents, fellows, and faculty who work or have rotated in a single family planning clinic after the clinic introduced this consent process. Participants were asked about their experiences obtaining informed consent from patients for examinations under anesthesia with learners. Interviews were audiorecorded, transcribed, and analyzed using modified grounded theory. All study procedures were institutional review board approved. RESULTS: Twenty interviews were performed, achieving thematic saturation, with 14 residents, 4 fellows, and 2 faculty members. Participants described initial discomfort with the consent process and their wording choices, which improved with increased familiarity and almost universal patient acceptance. Some participants felt that an informal training or practice before obtaining informed consent may have been helpful. Participants stressed the importance of this consent process to foster patient autonomy and choice. Participants reported that the fact that patients were presenting for abortion care did not influence their overall process or comfort level obtaining consent for pelvic examinations under anesthesia with learners; however, some noted that they gave patients more time to process the consent or used more intentional language during these encounters. CONCLUSIONS: Physicians desire and accept the integration of a formal consent process for examinations under anesthesia with learners at the time of abortion.

Sexual and Gender Minority Patients' First Pelvic Examination Experiences: What Clinicians Need to Know.

STUDY OBJECTIVE: The aim of this study was to identify factors that influence the first pelvic exam experiences of sexual and gender minority (SGM) adolescents and young adults who were assigned female at birth (AFAB). METHODS: Using purposive sampling, we recruited SGM AFAB individuals, ages 18-24, who had had at least 1 pelvic examination. Semi-structured interviews and an iterative approach allowed for the emergence of factors influencing the first pelvic exam experience. Items included in the final code directory had a Krippendorff's alpha intercoder reliability score greater than 0.7. Interviews were analyzed using ATLAS.ti. RESULTS: Thirty participants completed interviews. Fourteen participants identified as bisexual, 2 as gay, 1 as lesbian, 3 as pansexual, 8 as queer, and 2 as straight/heterosexual. Sixteen participants identified as cisgender, 9 as genderqueer/gender nonconforming, and 5 as transgender. Factors influencing the first pelvic exam experience were organized as patient- or clinician-level factors. The patient-level factors of gender identity, sexual orientation, history of sexual trauma, and participant's relationship to their body were central factors influencing the exam experience. Speculum insertion during the exam induced anxiety and pain for some. The clinician-level factors of gender, age, and race or ethnicity influenced the exam experience. Most participants preferred detailed communication. Participants offered recommendations to ensure gender-affirming, patient-centered care during the first pelvic exam. CONCLUSION: SGM AFAB individuals identified patient- and clinician-level factors influencing their first pelvic exam experiences. This study underscores the need for changes in medical education and health systems to ensure that SGM AFAB individuals have their needs met and feel comfortable in reproductive health settings.