Risk of unintended pregnancy based on intended compared to actual contraceptive use.

BACKGROUND: After initiating a new contraceptive method, the provider has little control of how or whether that method is used. OBJECTIVE: We sought to compare unintended pregnancy rates by the initial chosen contraceptive method after counseling to traditional contraceptive effectiveness in the same study population. STUDY DESIGN: The Contraceptive CHOICE Project provided reversible contraception to 9252 women at no cost during 2-3 years of follow-up. We performed 2 analyses of contraceptive efficacy in this prospective cohort: (1) intent-to-use (ITU), grouping participants based on their chosen method at enrollment; and (2) as-used, categorizing participant time according to the method used. In ITU analysis, switching of methods and method continuation were not considered, as we wanted to assess outcomes based on the method chosen at baseline. We used Cox proportional hazards models to compare rates of unintended pregnancy. RESULTS: During 20,017 person-years, we identified 615 unintended pregnancies. In ITU analysis, pregnancy rates were 5.3, 5.5, 2.0, 1.7, and 1.9 per 100 person-years for women initiating oral, injectable, implantable, copper, and hormonal intrauterine contraception (IUC) at baseline, respectively. The adjusted hazard ratio for injectable contraception compared to hormonal IUC was 2.4 (95% confidence interval, 1.8-3.3). Delaying initiation of IUC or implantable contraception increased unintended pregnancies by 60% (adjusted hazard ratio, 1.6; 95% confidence interval, 1.2-2.0). In as-used analysis, pregnancy rates were 6.7, 1.6, 0.2, 0.6, and 0.2 per 100 person-years for women using oral, injectable, implantable, copper, and hormonal IUC, respectively. CONCLUSION: Although highly effective in the as-used analysis, women initially choosing injectable contraception had pregnancy rates similar to oral contraception and significantly worse than IUC or implantable contraception. Despite switching and discontinuation, women choosing an IUC or implantable contraception at baseline were much less likely to have an unintended pregnancy compared to those selecting other methods.

Update on abortion policy.

PURPOSE OF REVIEW: To review the status of antiabortion restrictions enacted over the last 5 years in the United States and their impact on abortion services. RECENT FINDINGS: In recent years, there has been an alarming rise in the number of antiabortion laws enacted across the United States. In total, various states in the union enacted 334 abortion restrictions from 2011 to July 2016, accounting for 30% of all abortion restrictions since the legalization of abortion in 1973. Data confirm, however, that more liberal abortion laws do not increase the number of abortions, but instead greatly decrease the number of abortion-related deaths. Several countries including Romania, South Africa and Nepal have seen dramatic decreases in maternal mortality after liberalization of abortion laws, without an increase in the total number of abortions. In the United States, abortions are incredibly safe with very low rates of complications and a mortality rate of 0.7 per 100 000 women. With increasing abortion restrictions, maternal mortality in the United States can be expected to rise over the coming years, as has been observed in Texas recently. SUMMARY: Liberalization of abortion laws saves women's lives. The rising number of antiabortion restrictions will ultimately harm women and their families.

Immediate versus delayed IUD insertion after uterine aspiration.

BACKGROUND: Intrauterine devices (IUDs) provide highly effective, reversible, long-term contraception that is appropriate for many women after first-trimester uterine aspiration. However, the effects of immediate versus delayed IUD insertion after uterine aspiration on rates of complications and IUD use are uncertain. METHODS: We performed a randomized noninferiority trial involving women undergoing uterine aspiration for induced or spontaneous abortion at 5 to 12 weeks of gestation who desired an IUD. Subjects were randomly assigned (in a 5:6 ratio) to IUD insertion immediately after the procedure or 2 to 6 weeks afterward (delayed insertion). The primary outcome was the rate of IUD expulsion 6 months after IUD insertion; an expulsion rate 8 percentage points higher in the immediate-insertion group was defined as inferior. RESULTS: Among 575 women who underwent randomization, an IUD was inserted in 100% (258 of 258) of the women in the immediate-insertion group and in 71.3% (226 of 317) of those in the delayed-insertion group (difference, 28.7 percentage points; 95% confidence interval [CI], 23.7 to 33.7). The 6-month expulsion risk was 5.0% (13 of 258 women) after immediate insertion and 2.7% (6 of 226) after delayed insertion (difference, 2.3 percentage points; 95% CI, -1.0 to 5.8), which was consistent with the predefined criterion for noninferiority. Six-month rates of IUD use were higher in the immediate-insertion group (92.3%, vs. 76.6% after delayed insertion; P<0.001). Adverse events were rare and did not differ significantly between groups. No pregnancies occurred in the immediate-insertion group; five occurred in the delayed-insertion group (P=0.07), all in women who never received an IUD. CONCLUSIONS: The 6-month rate of expulsion of an IUD after immediate insertion was higher than but not inferior to that after delayed insertion. Immediate insertion resulted in higher rates of IUD use at 6 months, without an increased risk of complications. (Funded by the Susan Thompson Buffett Foundation; ClinicalTrials.gov number, NCT00562276.).

Cabergoline for Lactation Inhibition After Second-Trimester Abortion or Pregnancy Loss: A Randomized Controlled Trial.

OBJECTIVE: To assess cabergoline's efficacy at decreasing breast symptoms after second-trimester abortion or pregnancy loss. METHODS: This was a double-blinded, block-randomized superiority trial comparing cabergoline 1 mg once to placebo for preventing bothersome breast engorgement after second-trimester uterine evacuation. We enrolled pregnant people at 18-28 weeks of gestation who were English- or Spanish-speaking and without contraindication to the study drug. Participants completed a validated, piloted, electronic survey at baseline and at multiple timepoints through 2 weeks postprocedure to assess breast symptoms, side effects, and bother. Our primary outcome was any breast symptoms (a composite of engorgement, milk leakage, tenderness, and need for pain relief) on day 4; we planned to enroll 80 patients to show a 30% difference in breast symptoms (80% power, α=0.049). A subgroup of participants returned for serum prolactin levels. RESULTS: After screening 150 patients from April 2021 to June 2022, we enrolled 73 participants. Baseline demographics were balanced between groups: median gestational age was 21 weeks (range 18-26 weeks), 56.2% of participants were nulliparous, 34.2% self-identified as Hispanic, and 37.0% had public insurance. At baseline, reported breast symptoms were similar between groups. Among 69 participants who returned surveys on day 4, significantly fewer participants receiving cabergoline reported any breast symptoms compared with placebo (27.8% vs 97.0%, P<.001) (primary outcome) and fewer reported significant bother (2.8% vs 33.3%, P=.001) (secondary outcome). These differences persisted through day 14. Reported incidence and severity of bother from side effects were similar between groups: most common were constipation, fatigue, and headache. Serum prolactin levels were similar at baseline. On day 4, mean serum prolactin level was 6.5 ng/mL (SD 2.2) for those who received cabergoline and 18.0 ng/mL (SD 5.9) for placebo (P=.049). CONCLUSION: Cabergoline is an effective and well-tolerated strategy to prevent breast symptoms after second-trimester abortion or pregnancy loss. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT04701333.

Gabapentin as an adjunct for pain management during dilation and evacuation: A double-blind randomized controlled trial.

OBJECTIVES: To assess the analgesic efficacy of preoperative gabapentin among patients undergoing dilation and evacuation (D&E) with moderate sedation. STUDY DESIGN: We conducted a randomized, controlled, double-blind trial among patients undergoing same-day D&E at 14 to 19 weeks gestation under moderate sedation. We randomized participants 1:1 to gabapentin 600 mg or placebo after cervical preparation at least 1 hour prior to D&E. We assessed pain using a 100-mm visual analog scale before, during, and after the procedure. The primary outcome was postoperative recall of maximum procedural pain with a 13-mm a priori threshold for clinical significance. We standardized initial fentanyl and midazolam dosing. We assessed satisfaction with pain control, nausea, and vomiting via Likert scales and anxiety using a validated instrument. RESULTS: We enrolled 126 participants and randomized 61 to gabapentin and 65 to placebo, with study medication administered a mean of 211 (SD 64) minutes preoperatively. Recall of maximum pain was 41 mm for gabapentin and 49 mm for placebo (p = 0.24). Gabapentin resulted in reduced pain during uterine aspiration (56 vs 71 mm, p= 0.003) compared to placebo, but not for any other time points. The gabapentin group had higher satisfaction (78% vs 65% very or somewhat satisfied, p= 0.01). Median fentanyl dose was lower in the gabapentin group (75 vs 100 mcg, p = 0.005). Midazolam dose, nausea, vomiting, and anxiety did not differ between groups. No serious adverse events occurred in the gabapentin group. Sedation reversal was not required. CONCLUSIONS: The addition of gabapentin to moderate sedation during D&E did not result in lower maximum recalled procedural pain. Gabapentin resulted in reduced intra-operative pain during uterine aspiration and increased satisfaction with pain control. IMPLICATIONS: Gabapentin reduces intraoperative pain and improves satisfaction with pain management when administered prior to second-trimester surgical abortion and may be considered as an adjunct to intravenous sedation. Moderate sedation may impair assessment and recall of pain. Additional research is needed to identify the most effective pain management regimens for D&E.

Transabdominal lidocaine to induce fetal demise: a cohort study.

INTRODUCTION: We sought to assess the efficacy of transabdominal intrafetal lidocaine to achieve fetal demise before pregnancy termination. METHODS: This study was a retrospective cohort analysis of patients undergoing transabdominal intrafetal lidocaine injections prior to abortion procedures after 24 weeks from January 2018 to June 2020 at DuPont Clinic, an outpatient obstetrics and gynaecology clinic in Washington, DC, USA. We recorded data on maternal factors, gestational age, time of injection and fetal asystole, and injection dose and location. We defined successful intrafetal lidocaine injection as asystole achieved prior to the patient leaving the clinic. RESULTS: We performed injections in 338 fetuses in 335 patients, with a median gestational age of 27 weeks and 6 days (range 24-32 weeks). Lidocaine dose was 200-240 mg in 310 cases (91.7%) and 400-480 mg in 27 cases (8.0%) without difference in success (p>0.05). Lidocaine successfully induced fetal demise with one injection in 331 cases (97.9%). A second injection was required to induce demise for five fetuses (1.5%). Intracardiac injection was successful in 280 of 285 cases (98.3%), with asystole confirmed within 1 min in 75% of cases. Intrathoracic injection caused asystole in 45 of 47 cases (95.7%), with asystole confirmed within 2 min in 75% of cases. Success was not significantly associated with gestational age, body mass index or parity (p>0.05). One patient reported lidocaine-related side effects (0.3%). CONCLUSIONS: Intrafetal lidocaine is a safe and effective method of inducing fetal demise. Intracardiac injection achieves fetal asystole almost immediately. Intrathoracic injection is also highly effective.

A factorial-design randomized controlled trial comparing misoprostol alone to Dilapan with misoprostol and comparing buccal to vaginal misoprostol for same-day cervical preparation prior to dilation & evacuation at 14 weeks 0 days-19 weeks 6 days gestation.

OBJECTIVES: To compare procedure times following same-day cervical preparation using misoprostol 400 mcg alone or misoprostol 400 mcg plus hygroscopic dilators for dilation and evacuation (D&E) before 20 weeks gestation and to compare side effects of buccal and vaginal misoprostol administration. STUDY DESIGN: We randomized women undergoing D&E at 14 weeks 0 days-19 weeks 6 days gestation to receive (1) hygroscopic dilators or not and (2) buccal or vaginal misoprostol using a 2 × 2 factorial design. We assessed two primary outcomes: (1) total procedure time, defined as time to insert hygroscopic dilators plus D&E time, and (2) side effects of misoprostol 4-6 h after initiation of cervical preparation using a 5-point Likert scale assessing nausea, emesis, diarrhea, chills and cramps. RESULTS: We randomized 163 women and 161 completed the study. We completed all procedures in one day. Mean total procedure time was 14.0 and 10.8 min. with and without hygroscopic dilators (difference 3.2 minutes, 95% CI 1.7, 4.6). Mean D&E procedure time was 0.7 (95% CI -0.8, 2.1) min longer without hygroscopic dilators. Initial cervical dilation was 15.6 and 11.7 mm with and without hygroscopic dilators (difference 3.9 mm, 95% CI 3.1, 4.8). Participants receiving buccal misoprostol reported less chills (1.9) than women receiving vaginal misoprostol (2.3), p = 0.04. CONCLUSIONS: Hygroscopic dilators with misoprostol requires more time and increases cervical dilation without shortening D&E time when used for cervical preparation 4-6 h prior to D&E before 20 weeks. Women receiving vaginal misoprostol may have more chills compared to buccal misoprostol. IMPLICATIONS: Adding hygroscopic dilators to misoprostol for same day D&E procedures at less than 20 weeks gestation increases total intervention time without reducing D&E time and is less favored by patients. Clinical judgment requires balancing relative effectiveness with patient preference. Further studies should evaluate the side effect profile of vaginal misoprostol.

Ultrasonographic endometrial thickness after medical and surgical management of early pregnancy failure.

OBJECTIVE: We sought to compare endometrial thickness after misoprostol or dilation and curettage (D&C) for early pregnancy failure and to assess the predictive value of endometrial thickness for subsequent D&C after misoprostol treatment. METHODS: In a randomized trial of early pregnancy failure management, 491 women were treated with misoprostol vaginally, and 161 were treated with D&C. Transvaginal ultrasonography was planned for 2 and 14 days after misoprostol treatment, and 14 days after D&C. RESULTS: The mean endometrial thickness 14 days after treatment was 9.0 mm for the misoprostol group and 6.9 mm for the D&C group, (difference 2.1 mm, 95% confidence interval [CI] 1.0-3.2). After the ultrasonograms 2 and 14 days after misoprostol, 13 (3.8%) and 12 (3.2%) women, respectively, subsequently underwent D&C. Women requiring D&C after successful expulsion had significantly greater endometrial thickness than those who did not at 2 days (mean difference 5.2 mm, 95% CI 1.6-8.8) and 14 days (mean difference 5.5 mm, 95% CI 2.3-8.8) after misoprostol. However, endometrial thickness was a poor predictor of subsequent D&C. The areas under the receiver operating characteristic curves for endometrial thickness at 2 and 14 days were 0.71 and 0.73, respectively. Regardless of cutoff values used for predicting subsequent D&C, endometrial thickness had a positive predictive value of 40% or less. CONCLUSION: The difference in endometrial thickness between misoprostol treatment and D&C for early pregnancy failure is not clinically significant. Endometrial thickness is not a useful predictor of subsequent surgical intervention after successful expulsion of the gestational sac after misoprostol for early pregnancy failure. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov,www.clinicaltrials.gov, NCT00177333 LEVEL OF EVIDENCE: I.

Misoprostol for treatment of early pregnancy failure in women with previous uterine surgery.

OBJECTIVE: Misoprostol use in early pregnancy may incur a risk of uterine rupture in women with previous uterine surgery. STUDY DESIGN: We analyzed 488 women who received misoprostol 800 microg vaginally in a study that evaluated medical and surgical management of early pregnancy failure. Subjects received a repeat misoprostol dose if expulsion was not confirmed 2 days after treatment. We compared efficacy, acceptability, and safety in subjects with a history (n = 78 women) or absence (n = 410 women) of uterine surgery, defined as cesarean delivery or myomectomy. RESULTS: Expulsion rates after a single misoprostol dose (69% vs 72%; P = .64) and overall success at 30 days (82% vs 85%; P = .50) were comparable. Pain, bleeding, complications, and acceptability did not differ. No uterine ruptures occurred (95% CI, 0, 3.8%). CONCLUSION: Misoprostol treatment for early pregnancy failure had similar success, acceptability, and complications in women with and without previous uterine surgery.

Baseline colposcopic findings in women entering studies on female vaginal products.

BACKGROUND: Colposcopy is commonly used for genital tract assessment in safety studies on female-controlled vaginal products. However, findings that are considered "lesions" are present even without product use. We sought to categorize the type and frequency of lesions found on baseline colposcopy evaluation in healthy women to describe natural lower genital tract changes due to environmental factors. STUDY DESIGN: We reviewed demographic information and baseline colposcopic examination findings from subjects in 13 studies of vaginal products. All studies included an aim of identifying colposcopic changes as a means of monitoring safety of a vaginal product or device. Colposcopic evaluations were performed according to the WHO/CONRAD Manual for the Standardization of Colposcopy for the Evaluation of Vaginal Products. RESULTS: A total of 317 lesions were found on 569 baseline colposcopy evaluations, with 192 women (34%) having at least one lesion. The most commonly identified lesions were petechiae and erythema, accounting for 45% and 37% of lesions, respectively. Seventy-three percent of lesions were located on the cervix, whereas 15% of lesions were located on the vaginal wall or fornix. CONCLUSIONS: Lower genital tract colposcopic findings are common in healthy women. Such findings likely represent normal physiologic changes. Future research needs to address whether routine colposcopic examination is necessary in the evaluation of new vaginal products.

Medical abortion outcomes after a second dose of misoprostol for persistent gestational sac.

BACKGROUND: We sought to examine outcomes after a second dose of misoprostol was given at a 1-week follow-up visit after medical abortion for the presence of a persistent gestational sac (GS) on ultrasound examination. STUDY DESIGN: We examined outcomes in women who were enrolled in two randomized trials of medical abortion regimens. Pregnant women up to 63 days' gestation received mifepristone followed by misoprostol 800 mcg vaginally either 24 h later, 6-8 h later or within 15 min. Participants in both studies returned for an evaluation, including transvaginal ultrasonography, approximately 7 days after initiating treatment. We included women with a GS present at the follow-up visit. Subjects who had not expelled the GS received a second dose of misoprostol 800 mcg vaginally. Participants returned approximately 1 week later and were contacted by telephone 5 weeks after treatment. RESULTS: Of 1972 women who had a follow-up ultrasound examination within 11 days of treatment, a persistent GS was identified in 82 women (4.2%) of whom 68 opted to receive a second dose of misoprostol. All 68 women returned for follow-up evaluation and 42 (62%) expelled the GS. In the 26 women with an embryonic pole within the persistent sac, expulsion occurred in 5 (36%) of 14 with and 7 (54%) of 13 without gestational cardiac activity (GCA) (p = .45). Of the 14 pregnancies with GCA, only 5 (36%) had GCA at follow-up. CONCLUSIONS: More than half of women with a persistent GS after medical abortion will expel the pregnancy when treated with a second dose of misoprostol. One-third of women who have a GS with cardiac activity will expel the GS with a second dose of misoprostol, making a second dose a reasonable option.

The prevalence of domestic violence in volunteers for abortion and contraceptive research studies.

BACKGROUND: The prevalence of domestic violence (DV) in research subjects has not been evaluated. In the general population, about 25% of women report DV. We hypothesize that participants in research studies would report similar rates of abuse to women in the general population and that subjects in abortion studies would report higher rates of abuse than women in other gynecologic studies. STUDY DESIGN: We included a modified abuse assessment questionnaire as a routine section of the medical history obtained for 256 women who were enrolling in abortion, contraceptive and other gynecologic research studies. Rates of reported recent or lifetime abuse, defined as physical or sexual violence, were compared for women in each study group by chi(2) analysis and Fisher's Exact Tests. A multivariable analysis with stepwise logistic regression was used to compare study groups. RESULTS: The overall rate of ever-experience DV was 18% for the study population. Lifetime rates of DV were 17%, 15% and 30% in women enrolling in abortion, contraceptive and other gynecologic research studies, respectively (p=.17). Abuse within the last 2 months was reported by 1%, 0% and 0% of women, respectively (p=.50). After controlling for age, race, ethnicity, gravity, parity and marital status, the rates of violence did not vary between study groups. CONCLUSION: We found the rates of DV in women who volunteer for research studies are similar to those reported for women in the general population. Subjects in abortion research studies do not report DV more frequently than women in contraceptive or other gynecologic studies.

Measuring the effects of unintended pregnancy on women's quality of life.

BACKGROUND: This study was conducted to assess the potential impact of an unintended pregnancy on women's quality of life. STUDY DESIGN: We asked 192 nonpregnant women to report how they would feel if they learned that they were pregnant using a visual analog scale (VAS), a time trade-off (TTO) metric, a standard gamble (SG) metric and a willingness-to-pay (WTP) metric. RESULTS: Women's anticipated responses to an unintended pregnancy varied widely. Using a VAS, 8% reported pregnancy would make them feel like they were dying. To avoid pregnancy, 28% of women were willing to trade time from the end of their life (TTO), 16% of women were willing to accept an immediate risk of death (SG) and 60% of women were willing to pay some amount of money (WTP). On average, women, using the VAS, TTO and SG metrics, reported that an unintended pregnancy would create a health utility state (where 0 represents death and 1 represents perfect health) of 0.487, 0.992 and 0.997, respectively. CONCLUSION: The anticipated effects of pregnancy on women's quality of life should be integrated into cost-effectiveness analyses of family planning services.

Impact of immediate postabortal insertion of intrauterine contraception on repeat abortion.

BACKGROUND: Of the 1.3 million abortions performed annually in the United States, approximately half are repeat procedures. Immediate postabortal intrauterine device (IUD) insertion is a safe, effective, practical and underutilized intervention that we hypothesize will significantly decrease repeat unintended pregnancy and abortion. STUDY DESIGN: All women receiving immediate postabortal IUD insertion in eight clinics of a Northern California Planned Parenthood agency during a 3-year period comprise the IUD cohort. We selected a cohort of controls receiving abortions but choosing other, non-IUD contraception on the day of the abortion visit in a 2:1 ratio matched by date of abortion. We obtained follow-up data on repeat abortions within the agency for both cohorts through 14 months after the 3-year period. We evaluated differences in repeat abortion between cohorts. All analyses were intent-to-treat. RESULTS: Women who received an immediate postabortal IUD had a lower rate of repeat abortions than controls (p<.001). Women who received a postabortal IUD had 34.6 abortions per 1000 woman-years of follow-up compared to 91.3 for the control group. The hazard ratio for repeat abortion was 0.38 [95% confidence interval (CI), 0.27-0.53] for women receiving a postabortal IUD compared to controls. When adjusted for age, race/ethnicity, marital status, and family size, the hazard ratio was 0.37 (95% CI, 0.26-0.52). CONCLUSION: Immediate postabortal intrauterine contraception has the potential to significantly reduce repeat abortion.

Increasing intrauterine contraception use by reducing barriers to post-abortal and interval insertion.

BACKGROUND: We hypothesize that barriers to IUD insertion are central to low utilization in the USA. This study evaluates methods to minimize barriers, including post-abortal insertion, staff training and simplified screening. STUDY DESIGN: We obtained data on IUD utilization during three study periods: a control period (Period 1), a period after initiating post-abortal insertion and staff training (Period 2), and a period with these interventions plus simplified screening for interval insertions (Period 3). We evaluated IUD utilization, associated complications and utilization at a similar local agency in which the interventions were not implemented. RESULTS: We inserted 2172 IUDs during the study, including 1493 interval and 679 post-abortal insertions. In the control period, there were 28 monthly IUD insertions on average, compared to 71 (a 151% increase) and 122 (a 334% increase) in Periods 2 and 3, respectively. IUD utilization at the nearby agency remained relatively constant. Complications remained low. CONCLUSIONS: IUD utilization can be substantially increased through relatively simple, low-cost interventions, with significant potential to reduce unintended pregnancy.

Contraceptive effectiveness of immediate compared with delayed insertion of intrauterine devices after abortion: a decision analysis.

OBJECTIVE: To model rates of pregnancy and repeat abortion among women choosing intrauterine contraception after an abortion when the intrauterine device (IUD) is inserted immediately after the procedure or at a follow-up visit. METHODS: We created an evidence-based decision model of women desiring to avoid pregnancy for the 12 months after an abortion. Base case assumptions were pregnancy rates of 0.5% with an IUD and 20% without an IUD, 1-year IUD continuation rate of 80%, an additional 5% risk of IUD expulsion with immediate insertion, and a 35% risk of not returning for a follow-up visit for IUD insertion. Sensitivity analyses and Monte Carlo simulation were performed. RESULTS: Immediate IUD insertion after abortion prevented 52 pregnancies over the following year for every 1,000 women modeled by using base case assumptions. Sensitivity analyses show the model to be most dependent on the rate of expulsion in the immediate-insertion group and the proportion not returning in the delayed-insertion group. Monte Carlo analysis showed that immediate insertion resulted in fewer pregnancies than delayed insertion in 91% of scenarios, with an absolute mean difference of 28 pregnancies per 1,000 women in the initial year after abortion. If 20% of U.S. women undergoing abortion opted for immediate insertion, an estimated 20,000 repeat abortions would be prevented in the first year. CONCLUSION: Women who have an IUD inserted immediately after an abortion are expected to have fewer pregnancies and repeat abortions than women scheduled for insertion of an IUD at a follow-up visit.

Race, insurance status, and tubal sterilization.

OBJECTIVE: To examine the independent effects of race or ethnicity and insurance status on use of tubal sterilization rates. METHODS: This study used cross-sectional data collected by the 2002 National Survey of Family Growth. The survey is designed to represent women and men aged 15-44 years in the household population of the United States. Our main outcome measure was tubal sterilization at any time before interview. A multivariable logistic regression model was used to estimate the effects of race or ethnicity and insurance status on rates of tubal sterilization after adjusting for important confounders. RESULTS: The sample consisted of 7,643 women: 66% were white, 15% were Hispanic, and 14% were African American; 68% had private insurance and 32% had public or no insurance. After adjusting for age, insurance status, parity, income, education, marital status, and religion, African-American women were more likely than white women to undergo tubal sterilization (adjusted odds ratio 1.43, 95% confidence interval 1.08-1.88). After adjusting for age, race or ethnicity, parity, income, education, marital status, and religion, women with public or no insurance were more likely to undergo sterilization compared with women with private insurance (adjusted odds ratio 1.38, 95% confidence interval 1.09-1.74). CONCLUSION: African-American women and women with no or public insurance were more likely to have undergone tubal sterilization compared with white women and women with private insurance, respectively. Additional research to identify factors that influence women's decision to undergo sterilization is warranted. LEVEL OF EVIDENCE: II.

Recurrent spontaneous abortion and skewed X-inactivation: is there an association?

OBJECTIVE: The purpose of this study was to determine whether there is an association between skewed X-inactivation and recurrent spontaneous abortion in a large, well-defined sample of women with recurrent loss. STUDY DESIGN: X-chromosome inactivation patterns were compared in 5 groups of women. Group 1 (recurrent spontaneous abortion) consisted of 357 women with 2 or more spontaneous losses. In group 2 (infertility), there were 349 subjects from infertility practices recruited at the time of a positive serum beta-human chorionic gonadotropin. Group 3 (spontaneous abortion) women (n = 81) were recruited at the time of an ultrasound diagnosis of an embryonic demise or an anembryonic gestation. Groups 4 (primiparous) and 5 (multiparous) were healthy pregnant subjects previously enrolled in another study to determine the incidence and cause of pregnancy complications, such as preeclampsia and intrauterine growth restriction. The Primiparous group included 114 women in their first pregnancy, whereas the Multiparous group consisted of 79 women with 2 or more pregnancies but without pregnancy loss. RESULTS: The rate of extreme skewing (90% or greater) in the recurrent spontaneous abortion population was 8.6%, and not statistically different from any of the other groups, except the Primiparous group (1.0%, P < .01). The incidence of X-inactivation skewing of 90% or greater was no different whether there had been at least 1 live birth (9.9%), or no previous live births and at least 3 losses (5.6%, P > .05). When age and skewing of 90% or greater are compared, subjects with extreme skewing have a mean age of 2 years older than those without extreme skewing (P < .05). CONCLUSION: Skewed X-inactivation is not associated with recurrent spontaneous abortion but is associated with increasing maternal age.

Knowledge of and perceived access to emergency contraception at two urgent care clinics in California.

BACKGROUND: California allowed women access to emergency contraception (EC) without a physicians' prescription in 2002. METHODS: To assess knowledge of and perceived access to EC among California women outside of family planning settings, we administered a computerized survey to women, age 18-45 years, who could become pregnant, in the waiting areas of two urgent care clinics in San Francisco in 2005. RESULTS: Four hundred forty-six women were enrolled. Most women [87%; 95% confidence interval (95% CI), 83-89%] in this well-educated (48% had college degrees), ethnically diverse sample knew that a postcoital contraceptive exists. However, many women (32%; 95% CI, 28-37%) did not know EC is currently available in California. Only 49% of women knew that using EC will have no adverse effect on their future fertility and only 15% knew that EC will not cause a miscarriage or birth defects if used by a woman who is pregnant. Seven percent thought EC was not at all effective and 27% thought EC was somewhat or very unsafe. Eight percent had EC at home for future use. CONCLUSIONS: Functional knowledge of EC remains limited in California. Public education campaigns are needed to allow women to benefit from pharmacy direct access to EC.