A Prediction Model for Pelvic Floor Recovery After Vaginal Birth With Risk Factors.

IMPORTANCE: Although parturients report few postpartum symptoms, birth is clearly associated with future symptom development. The ability to identify asymptomatic at-risk women would facilitate prevention. OBJECTIVE: The aim of the study was to develop a model predicting abnormal recovery in women at risk for childbirth-associated pelvic floor injury. STUDY DESIGN: Women undergoing first vaginal birth at high risk of pelvic floor injury underwent examinations and ultrasound imaging and completed 6-week and 6-month postpartum questionnaires. We defined "abnormal" recovery as having ≥1 of the following 3 findings: (1) levator ani injury, (2) decreased objective pelvic floor strength, and (3) Pelvic Organ Prolapse Quantification point Bp ≥0. Descriptive statistics and bivariate analyses compared "normal" and "abnormal" recovery. Birth characteristics, 6-week examinations, and questionnaires potentially predicted abnormal recovery at 6 months. Significant variables were included as candidates in the multivariable logistic regression predicting "abnormal" recovery after birth. RESULTS: Fifty-four women (63.5%) had normal and 31 (36.5%) had abnormal recovery at 6 months. At 6 weeks, women with abnormal recovery had decreased pelvic floor strength by Oxford scores (3 [2-5], 6 [2-8]; P = 0.002), lower point Bp (-1 [-3 to 0], -2 [-3 to -1]; P = 0.02), larger genital hiatus (4 [3 to 4], 3 [3 to 3.5]; P = 0.02), and higher levator ani injury rate (76.7%, 22.4%; P < 0.001). Between-group questionnaire differences were not clinically significant. Our final model included postpartum examination findings or birth characteristics: Oxford Scale, 6-week Pelvic Organ Prolapse Quantification GH strain, infant head circumference, and second stage ≥120 minutes. The area under the curve for predicting abnormal recovery at 6 months was 0.84, indicating a good sensitivity and specificity balance. CONCLUSION: The model identifies women at risk for an abnormal recovery trajectory.

The impact of antifibrotic use on long-term clinical outcomes in the pulmonary fibrosis foundation registry.

BACKGROUND: Idiopathic pulmonary fibrosis (IPF) is a devastating interstitial lung disease (ILD) with a high mortality rate. The antifibrotic medications pirfenidone and nintedanib have been in use since 2014 for this disorder and are associated with improved rate of lung function decline. Less is known about their long-term outcomes outside of the clinical trial context. METHODS: The Pulmonary Fibrosis Foundation Patient Registry was used for this study. Patients with an IPF diagnosis made within a year of enrollment were included. The treated group was defined as patients receiving either pirfenidone or nintedanib for at least 180 days. The untreated group did not have any record of antifibrotic use. Demographic data, comorbidities, serial lung function, hospitalization, and vital status data were collected from the registry database. The primary outcomes were transplant-free survival, time to first respiratory hospitalization, and time to 10% absolute FVC decline. Time-to-event analyses were performed utilizing Cox proportional hazards models and the log-rank test. Model covariates included age, gender, smoking history, baseline lung function, comorbidities, and oxygen use. RESULTS: The registry contained 1212 patients with IPF; ultimately 288 patients met inclusion criteria for the treated group, and 101 patients were designated as untreated. Patients treated with antifibrotics were significantly younger (69.8 vs. 72.6 years, p = 0.008) and less likely to have smoked (61.1% ever smokers vs. 72.3% never smokers, p = 0.04). No significant differences were seen in race, gender, comorbidities, or baseline pulmonary function between groups. The primary outcome of transplant-free survival was not significantly different between the two groups (adjusted HR 0.799, 95% CI 0.534-1.197, p = 0.28). Time to respiratory hospitalization was significantly shorter in the treated group (adjusted HR 2.12, 95% CI 1.05-4.30, p = 0.04). No significant difference in time to pulmonary function decline was seen between groups. CONCLUSIONS: This multicenter study demonstrated 63% of newly diagnosed IPF patients had continuous antifibrotic usage. Antifibrotics were not associated with improved transplant-free survival or pulmonary function change but was associated with an increased hazard of respiratory hospitalization. Future studies should further investigate the role of antifibrotic therapy in clinically important outcomes in real-world patients with IPF and other progressive ILDs.

Association of Childbirth With Medical Debt.

We evaluated the association between childbirth and having medical debt in collections and examined differences by neighborhood socioeconomic status. Among a statewide cohort of commercially insured pregnant (n=14,560) and postpartum (n=12,157) adults, having medical debt in collections was more likely among postpartum individuals compared with pregnant individuals (adjusted odds ratio [aOR] 1.36, 95% CI 1.27-1.46) and those in lowest-income neighborhoods compared with all others (aOR 2.18, 95% CI 2.02-2.35). Postpartum individuals in lowest-income neighborhoods had the highest predicted probabilities of having medical debt in collections (28.9%, 95% CI 27.5-30.3%), followed by pregnant individuals in lowest-income neighborhoods (23.2%, 95% CI 22.0-24.4%), followed by all other postpartum and pregnant people (16.1%, 95% CI 15.4-16.8% and 12.5%, 95% CI 11.9-13.0%, respectively). Our findings suggest that current peripartum out-of-pocket costs are objectively more than many commercially insured families can afford, leading to medical debt. Policies to reduce maternal-infant health care spending among commercially insured individuals may mitigate financial hardship and improve birth equity.

Association of the Mental Health Parity and Addiction Equity Act and the Affordable Care Act on severe maternal morbidity.

OBJECTIVE: This study aimed to characterize the association between Mental Health Parity and the Affordable Care Act and rates of severe maternal morbidity among a population of commercially insured individuals, including individuals with and without perinatal mood and anxiety disorders. METHODS: We conducted a serial, cross-sectional analysis of individuals with an inpatient delivery in Optum's Clinformatics® Data Mart Database from 2008 to 2021. We applied an interrupted time series model with autoregressive integrated moving average to evaluate changes in quarterly severe maternal morbidity rates. RESULTS: Adjusted severe maternal morbidity rates declined from 167.2 (95%CI: [152.6, 181.9]) per 10,000 deliveries in the first quarter of 2008 to 98.2 (95%CI: [83.5, 112.8]) per 10,000 deliveries in the last quarter of 2021. Severe maternal morbidity rates remained higher, but declined to a greater degree, among those with perinatal mood and anxiety disorders (435.6, 95%CI: [379.9, 491.3], to 165.0, 95%CI: [109.3, 220.8] per 10,000 deliveries) compared to those without (153.0, 95%CI: [140.7, 165.3] to 81.8, 95%CI: [69.6, 94.1] per 10,000 deliveries). CONCLUSION: The observed association suggests implementation of Mental Health Parity and Affordable Care Act may have played a role in lowering rates of severe maternal morbidity, particularly among individuals with perinatal mood and anxiety disorders.

Feasibility and acceptability of a toolkit-based process to implement patient-centered, immediate postpartum long-acting reversible contraception services.

BACKGROUND: National guidelines recommend that maternity systems provide patient-centered access to immediate postpartum long-acting reversible contraception (ie, insertion of an intrauterine device or implant during the delivery hospitalization). Hospitals face significant barriers to offering these services, and efforts to improve peripartum contraception care quality have met with mixed success. Implementation toolkits-packages of resources and strategies to facilitate the implementation of new services-are a promising approach for guiding clinical practice change. OBJECTIVE: This study aimed to develop a theory-informed toolkit, evaluate the feasibility of toolkit-based implementation of immediate postpartum long-acting reversible contraception care in a single site, and refine the toolkit and implementation process for future effectiveness testing. STUDY DESIGN: We conducted a single-site feasibility study of the toolkit-based implementation of immediate postpartum contraception services at a large academic medical center in 2017 to 2020. Based on previous qualitative work, we developed a theory-informed implementation toolkit. A stakeholder panel selected toolkit resources to use in a multicomponent implementation intervention at the study site. These resources included tools and strategies designed to optimize implementation conditions (ie, implementation leadership, planning, and evaluation; the financial environment; engagement of key stakeholders; patient needs; compatibility with workflow; and clinician and staff knowledge, skills, and attitudes). The implementation intervention was executed from January 2018 to April 2019. Study outcomes included implementation outcomes (ie, provider perceptions of the implementation process and implementation tools [assessed via online provider survey]) and healthcare quality outcomes (ie, trends in prenatal contraceptive counseling, trends in immediate postpartum long-acting reversible contraceptive utilization [both ascertained by institutional administrative data], and the patient experience of contraceptive care [assessed via serial, cross-sectional, online patient survey items adapted from the National Quality Forum-endorsed, validated Person-Centered Contraceptive Counseling measure]). RESULTS: In the implementation process, among 172 of 401 eligible clinicians (43%) participating in surveys, 70% were "extremely" or "somewhat" satisfied with the implementation process overall. In the prenatal contraceptive counseling, among 4960 individuals undergoing childbirth at the study site in 2019, 1789 (36.1%) had documented prenatal counseling about postpartum contraception. Documented counseling rates increased overall throughout 2019 (Q1, 12.5%; Q4, 51.0%) but varied significantly by clinic site (Q4, range 30%-79%). Immediate postpartum long-acting reversible contraception utilization increased throughout the study period (before implementation, 5.46% of deliveries; during implementation, 8.95%; after implementation, 8.58%). In the patient experience of contraceptive care, patient survey respondents (response rate, 15%-29%) were largely White (344/425 [81%]) and highly educated (309/425 [73%] with at least a 4-year college degree), reflecting the study site population. Scores were poor across settings, with modest improvements in the hospital setting from 2018 to 2020 (prenatal visits, 67%-63%; hospitalization, 45%-58%; outpatient after delivery, 69%-65%). Based on these findings, toolkit refinements included additional resources designed to routinize prenatal contraceptive counseling and support a more patient-centered experience of contraceptive care. CONCLUSION: A toolkit-based process to implement immediate postpartum long-acting reversible contraceptive services at a single academic center was associated with high acceptability but mixed healthcare quality outcomes. Toolkit resources were added to optimize counseling rates and the patient experience of contraceptive care. Future research should formally test the effectiveness of the refined toolkit in a multisite, prospective trial.

Trends In Primary Cesarean Section Rates Among Women With And Without Perinatal Mood And Anxiety Disorders.

Reducing the rate of cesarean sections among women considered at low risk for delivery by that method is a goal of Healthy People 2030. Prior research suggests that perinatal mood and anxiety disorders increase the risk for cesarean section, but data are limited. This cross-sectional study of commercially insured women examined the relationship between perinatal depression and anxiety disorders and primary (first-time) cesarean section rates, using administrative claims data for US in-hospital deliveries from the period 2008-17. Of the 360,225 delivery hospitalizations among 317,802 unique women, 24.0 percent included a delivery by primary cesarean section, and 3.1 percent carried a diagnosis of depression, anxiety, or both made during the index pregnancy. Using an adjusted generalized estimating equation, we found that the predicted probability of primary cesarean section was 3.5 percentage points higher, on average, among women with these disorders compared with those without them. Our findings confirm the importance of pursuing research to identify mechanisms by which perinatal depression and anxiety disorders increase the risk for primary caesarean section among women otherwise considered at low risk for delivery by that method, as well as effective interventions.

Financial Hardship Among Pregnant and Postpartum Women in the United States, 2013 to 2018.

Importance: Financial hardship affects health care access and health outcomes among peripartum women. Objective: To evaluate the prevalence of financial hardship among peripartum women over time and by insurance type and income. Design, Setting, and Participants: This cross-sectional study included peripartum women, defined as women aged 18 to 45 years who reported being currently pregnant or pregnant in the past 12 months, who participated in the National Health Interview Survey from 2013 to 2018. Data were analyzed from January to May 2021. Exposures: Current pregnancy or recent pregnancy as well as insurance type and income. Main Outcomes and Measures: Three measures of financial hardship within the last year were evaluated: (1) unmet health care need due to cost (unmet need for medical care or delayed or deferred medical care due to cost); (2) health care unaffordability (worry about paying for potential medical bills or existing medical debt); and (3) general financial stress (worry about subsistence spending [eg, monthly bills, housing]). Results: The study cohort included 3509 peripartum women, weighted to represent 1 050 789 women (2018: an estimated 36 045 of 184 018 [19.6%] Hispanic, 39 017 [21.2%] Black, and 97 366 [52.9%] White), with a mean (SD) age of 29 (6) years. Overall, from 2013 to 2018, 24.2% (95% CI, 22.6%-26.0%) of peripartum women reported unmet health care need, 60.0% (95% CI, 58.0%-61.9%) reported health care unaffordability, and 54.0% (95% CI, 51.5%-56.5%) reported general financial stress. The prevalence of financial hardship outcomes did not substantially change between 2013 and 2018 (unmet health care need in 2013: 27.9% [95% CI, 24.4%-31.7%]; in 2018: 23.7% [95% CI, 19.5%-28.6%]; health care unaffordability in 2013: 65.7% [95% CI, 61.1%-70.0%]; in 2018: 58.8% [95% CI, 53.4%-64.0%]; general financial stress in 2013: 60.6% [95% CI, 55.2%-65.8%]; in 2018: 53.8% [95% CI, 47.8%-59.8%]). Women with private insurance had lower odds of unmet need (adjusted odds ratio [aOR], 0.67; 95% CI, 0.52-0.87) but higher odds of health care unaffordability (aOR, 1.88; 95% CI, 1.49-2.36) compared with women with public insurance. Peripartum women with household incomes less than 400% of the federal poverty level had higher odds of unmet need (aOR, 1.50; 95% CI, 1.08-2.08) and unaffordable care (aOR, 1.98; 95% CI, 1.54-2.55) compared with those with household incomes 400% or more of federal poverty level. Conclusions and Relevance: These findings suggest that financial hardship among peripartum women in the United States was common from 2013 to 2018, including 24% of pregnant and postpartum women reporting unmet health care need and 60% reporting health care unaffordability. Women with private insurance and those living on lower incomes were more likely to experience unaffordable health care than women with pubic insurance and those with higher incomes, respectively. Targeted policy interventions are needed to improve health care affordability and promote overall economic security among peripartum women.

Mechanisms of hiatus failure in prolapse: a multifaceted evaluation.

INTRODUCTION AND HYPOTHESIS: We investigated whether factors influencing pelvic floor hiatal closure are inter-related or independent, hypothesizing that (1) hiatus size is moderately correlated with levator defect, pelvic floor muscle strength, and change in hiatus size with contraction and (2) urogenital hiatus (UGH) and levator hiatus (LH) measures are similar in patients with anterior wall (AW) and posterior wall (PW) prolapse. METHODS: This cross-sectional case-control study included subjects with AW prolapse (n = 50), PW prolapse (n = 50), and normal support (n = 50). Hiatus measurements and levator defects were assessed on MRI, and vaginal closure force was measured with an instrumented speculum. Pearson correlation coefficients and simple and multivariable linear regression models were performed. RESULTS: During contraction, LH narrowed 47% more in the PW compared to AW group (p = 0.001). With straining, LH lengthened 34% more in the PW than AW group (p < 0.001). With straining, UGH and LH lengthening was greater by 72% and 44% in those with major compared to no/minor defect (p < 0.001 and p = 0.004). Contraction strength explained, at most, 4% of UGH (r = 0.17) or LH (r = 0.20) shortening during contraction (r = 0.17 and r = 0.20, respectively), indicating that these factors are largely independent. After controlling for prolapse size, resting UGH and levator defect status were associated with straining UGH (p < 0.001, p = 0.004), but muscle strength and resting tone were not. CONCLUSIONS: Hiatus measures are complex and differ according to prolapse occurrence and type. They are, at best, only weakly correlated with pelvic floor muscle strength and movement during contraction.

Associations between Self-Reported Daily Affect Ratings and Sleep Duration during the First Two Weeks of Antidepressant Therapy.

Background: In the context of a randomized controlled trial evaluating the efficacy of augmenting fluoxetine treatment in young adults with major depressive disorder (MDD) using a modified repeated partial sleep deprivation protocol contrasting 2 weeks of restricted time in bed (i.e., 6 h TIB) to no time in bed restriction (i.e., 8 h TIB) the study examines whether sleep duration and the timing of repeated partial sleep deprivation predicts patient-reported affect ratings. Participants: Participants included 58 young adults with DSM-IV-diagnosed MDD. Methods: Daily ratings of affect and sleep were collected during the first 2 weeks of initiating fluoxetine treatment, yielding 630 person-days. Actigraphy monitoring was employed to assess compliance with time in bed condition. Results: Negative affect ratings and positivity ratios in the morning were more improved among participants assigned to the 6 h TIB condition compared to the 8 h TIB group. Participants whose bedtime was delayed by 2-h nightly demonstrated the most significant improvement in negative affect and positivity ratio during the first 2 weeks of fluoxetine therapy. Moreover, the trajectory of morning negative affect ratings in the first 2 weeks was predictive of remission after 4 weeks of fluoxetine therapy. Conclusions: These findings suggest that monitoring changes in daily affect may be a valuable marker of early treatment response in young adults with MDD.

Cost sharing, postpartum contraceptive use, and short interpregnancy interval rates among commercially insured women.

BACKGROUND: Increasing access to effective birth control after childbirth may meet many women's preferences and reduce short interpregnancy interval rates. Eliminating out-of-pocket costs for contraception has been reported to increase the use of the most effective methods among women with employer-based insurance, but the prevalence and effects of patient cost sharing for contraception have not been studied during the postpartum period. OBJECTIVE: This study aimed to examine the association between cost sharing for long-acting reversible contraception and postpartum contraception use patterns and pregnancies in the 12 months after delivery. STUDY DESIGN: We conducted a retrospective cohort analysis of commercially insured women undergoing childbirth from 2014 to 2018 using Optum's (Eden Prairie, MN) de-identified Clinformatics Data Mart database. This large national database includes nonretired employees and their dependents who are enrolled in health insurance plans sponsored by large- or medium-sized US-based employers. Women with 12 months of continuous enrollment postpartum were included. Childbirth, pregnancy, and contraceptive method (female sterilization, long-acting reversible contraceptives, other hormonal methods, and no prescription method observed) were identified using claims data. Contraceptive use patterns were observed at 3, 6, and 12 months postpartum and adjusted for individual and plan characteristics. Median out-of-pocket costs were $0 for sterilization and other hormonal methods but nonzero for long-acting reversible contraception. We therefore used simple and multivariable logistic regressions to examine the association between plan-level cost sharing (no cost sharing, $0; low cost sharing, >$0-<$200; and high cost sharing, ≥$200 out-of-pocket cost) for any long-acting reversible contraceptive insertion and contraceptive use patterns and short interpregnancy interval rates, controlling for age, household income, race and ethnicity, region, and insurance plan type. RESULTS: Among 25,298 plans with cost sharing data, we identified 172,941 women with continuous enrollment for 12 months postpartum, including 82,500 (47.7%) in no cost sharing, 22,595 (13.1%) in low cost sharing, and 67,846 (39.2%) in high cost sharing plans. The percentage of postpartum women in the study sample using any prescription contraceptive method was 39.5% by 3 months, 43.8% by 6 months, and 46.0% by 12 months. At all time points, postpartum women in no cost sharing plans had a higher predicted probability of long-acting reversible contraceptive use (eg, at 12 months: no cost sharing, 22.0%; low cost-sharing, 17.5%; high cost sharing, 18.3%; P<.001) and a lower predicted probability of no prescription method use (eg, at 12 months: no cost sharing, 51.8%; low cost sharing, 55.0%; high cost sharing, 54.9%; P<.001) than those in low or high cost sharing plans. Predicted probabilities of female sterilization and other hormonal method use did not differ substantively by plan cost sharing for long-acting reversible contraception at any time point. The proportion of women experiencing a short interpregnancy interval was low (1.9% by 3 months, 1.9% by 6 months, 2.0% by 12 months) and did not differ by plan cost sharing for long-acting reversible contraception at any time point. CONCLUSION: Out-of-pocket costs for long-acting reversible contraception influence the method of contraception used by postpartum women with employer-based insurance. Eliminating financial barriers to long-acting reversible contraception access after childbirth may help women initiate their preferred method and increase the use of long-acting reversible contraceptives among interested women who otherwise might utilize less effective methods.

Trends in Suicidality 1 Year Before and After Birth Among Commercially Insured Childbearing Individuals in the United States, 2006-2017.

Importance: Suicide deaths are a leading cause of maternal mortality in the US, yet the prevalence and trends in suicidality (suicidal ideation and/or intentional self-harm) among childbearing individuals remain poorly described. Objective: To characterize trends in suicidality among childbearing individuals. Design, Setting, and Participants: This serial cross-sectional study analyzed data from a medical claims database for a large commercially insured population in the US from January 2006 to December 2017. There were 2714 diagnoses of suicidality 1 year before or after 698 239 deliveries among 595 237 individuals aged 15 to 44 years who were continuously enrolled in a single commercial health insurance plan. Data were analyzed from October 2019 to September 2020. Main Outcomes and Measures: The primary outcome was diagnosis of suicidality in childbearing individuals 1 year before or after birth based on the identification of relevant International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) and ICD-10-CM diagnosis codes during at least 1 inpatient or 2 outpatient visits. Results: Of 595 237 included childbearing individuals, the mean (SD) age at delivery was 31.9 (6.4) years. A total of 40 568 individuals (6.8%) were Asian, 52 613 (8.6%) were Black, 73 172 (12.1%) were Hispanic, 369 501 (63.1%) were White, and 59 383 (9.5%) had unknown or missing race/ethnicity data. A total of 2683 individuals were diagnosed with suicidality 1 year before or after giving birth for a total of 2714 diagnoses. The prevalence of suicidal ideation increased from 0.1% per 100 individuals in 2006 to 0.5% per 100 individuals in 2017 (difference, 0.4%; SE, 0.03; P < .001). Intentional self-harm prevalence increased from 0.1% per 100 individuals in 2006 to 0.2% per 100 individuals in 2017 (difference, 0.1%; SE, 0.02; P < .001). Suicidality prevalence increased from 0.2% per 100 individuals in 2006 to 0.6% per 100 individuals in 2017 (difference, 0.4%; SE, 0.04; P < .001). Diagnoses of suicidality with comorbid depression or anxiety increased from 1.2% per 100 individuals in 2006 to 2.6% per 100 individuals in 2017 (difference, 1.4%; SE, 0.2; P < .001). Diagnoses of suicidality with comorbid bipolar or psychotic disorders increased from 6.9% per 100 individuals in 2006 to 16.9% per 100 individuals in 2017 (difference, 10.1%; SE, 0.2; P < .001). Non-Hispanic Black individuals, individuals with lower income, and younger individuals experienced larger increases in suicidality over the study period. Conclusions and Relevance: In this cross-sectional study of US childbearing individuals, the prevalence of suicidal ideation and intentional self-harm occurring in the year preceding or following birth increased substantially over a 12-year period. Policy makers, health plans, and clinicians should ensure access to universal suicidality screening and appropriate treatment for pregnant and postpartum individuals and seek health system and policy avenues to mitigate this growing public health crisis, particularly for high-risk groups.

Trends in Birth Rates After Elimination of Cost Sharing for Contraception by the Patient Protection and Affordable Care Act.

Importance: Reducing out-of-pocket costs is associated with improved patterns of contraception use. It is unknown whether reducing out-of-pocket costs is associated with fewer births. Objective: To evaluate changes in birth rates by income level among commercially insured women before (2008-2013) and after (2014-2018) the elimination of cost sharing for contraception under the Patient Protection and Affordable Care Act (ACA). Design, Setting, and Participants: This cross-sectional study used data from Clinformatics Data Mart database from January 1, 2008, to December 31, 2018, for women aged 15 to 45 years who were enrolled in an employer-based health plan and had pregnancy benefits for at least 1 year. Women without household income information and women with evidence of having undergone a hysterectomy were excluded. Exposure: Section 2713 of the ACA. Main Outcomes and Measures: The primary outcome was the proportion of reproductive-aged women with a live birth by year (measured yearly from 2008 to 2018 [11 time points]) within 3 income categories. The secondary outcome was the distribution of contraceptive method fills in 3 categories by year: (1) most effective methods (long-acting reversible contraception or sterilization), (2) moderately effective methods (pill, patch, ring, and injectable), and (3) no prescription or surgical method. Results: The analytic sample included 4 590 989 women (mean [SD] age; 30.8 [9.1] years in 2013; 3 069 053 White [66.9%]) enrolled in 47 721 health plans. A total of 500 898 participants (40.8%) resided in households with incomes less than 400% of the federal poverty level in 2013. In all 3 years (2008, 2013, and 2018), women in the lowest income category were younger than women in the other income groups (median range, 21-22 years vs 30-34 years) and in households with a higher median number of dependents (9-10 vs 2-4). There was an associated decrease in births in all income groups in the period after the elimination of out-of-pocket costs. The estimated probability of birth decreased most precipitously among women in the lowest income group from 8.0% (95% CI, 7.4%-8.5%) in 2014 to 6.2% (95% CI, 5.7%-6.7%) in 2018, representing a 22.2% decrease (P < .001). The estimated probability decreased in the middle income group by 9.4%, from 6.4% (95% CI, 6.3%-6.4%) to 5.8% (95% CI, 5.7%-5.8%) (P < .001), and in the highest income group by 1.8%, from 5.6% (95% CI, 5.6%-5.7%) to 5.5% (95% CI, 5.4%-5.5%) (P < .001) in the period after the elimination of cost sharing. Conclusions and Relevance: In this cross-sectional study, the elimination of cost sharing for contraception under the ACA was associated with improvements in contraceptive method prescription fills and a decrease in births among commercially insured women. Women with low income had more precipitous decreases than women with higher income, suggesting that enhanced access to contraception may address well-documented income-related disparities in unintended birth rates.

Breakdown in the expedited partner therapy treatment cascade: from reproductive healthcare provider to the pharmacist.

BACKGROUND: The rising incidence rates of sexually transmitted infections in the United States highlight the need for concurrent treatment of patients and their sexual partners. Expedited partner therapy allows healthcare providers to offer antibiotic prescriptions or medications to an index patient for distribution to their sexual partner(s) without evaluating the partner. We hypothesized that there was a gap between expedited partner therapy policy at the state level and its downstream implementation by community pharmacists. OBJECTIVE: The objectives of our study were to evaluate pharmacists' expedited partner therapy knowledge and practices in 41 expedited partner therapy-permissible US states, to determine whether there were differences in practice based on the length of time expedited partner therapy was permissible in the state and chlamydia incidence rates, and to measure the cost of expedited partner therapy treatment. STUDY DESIGN: A randomized cohort of pharmacists (n=335) was invited to complete a telephone interview from November 2017 through January 2018. Descriptive statistics were calculated and stratified by early, mid, and late expedited partner therapy-adopter status based on the year of the state's expedited partner therapy enactment and the state's chlamydia incidence rate. Fisher's exact test and 1-way analyses of variance were used to compare measures across strata. RESULTS: We had 143 pharmacists (42.7%) agree to complete the survey. Among our respondents, 40.6% (n=58/143) indicated that they were aware of expedited partner therapy; 14.7% (n=21/143) reported that they had ever received an expedited partner therapy prescription, and 97% (n=139/143) reported that they would dispense an expedited partner therapy prescription if they received 1 in the future. These findings were stable across the 6 strata defined by early, mid, or late expedited partner therapy-adopter and high or low incidence rates of chlamydia status. Mean cost of azithromycin 1000 mg and cefixime 400 mg for treatment of chlamydia and gonorrhea was $22.17 (95% confidence interval, 20.29-24.05) and $30.46 (95% confidence interval, 28.65-32.26), respectively. CONCLUSION: Fewer than one-half of the pharmacists were aware of expedited partner therapy. A small minority of pharmacists reported ever having received an expedited partner therapy prescription, regardless of the length of time expedited partner therapy had been legal in their states and the incidence of chlamydia. However, almost all pharmacists reported that they would dispense an expedited partner therapy prescription if they received 1. Additionally, costs were high for expedited partner therapy for self-pay patients. These data suggest that there are opportunities to increase expedited partner therapy utilization by healthcare providers, patients, and pharmacists.

Racial and Ethnic Disparities in Perinatal Insurance Coverage.

OBJECTIVE: To measure the association between race-ethnicity and insurance status at preconception, delivery, and postpartum and the frequency of insurance gaps and transitions (disruptions) across these time points. METHODS: We conducted a cross-sectional analysis of survey data from 107,921 women in 40 states participating in the Centers for Disease Control and Prevention's Pregnancy Risk Assessment and Monitoring System from 2015 to 2017. We calculated unadjusted estimates of insurance status at preconception, delivery, and postpartum and continuity across these time points for seven racial-ethnic categories (white non-Hispanic, black non-Hispanic, indigenous, Asian or Pacific Islander, Hispanic Spanish-speaking, Hispanic English-speaking, and mixed race or other). We also examined unadjusted estimates of uninsurance at each perinatal time period by state of residence. We calculated adjusted differences in the predicted probability of uninsurance at preconception, delivery, and postpartum using logistic regression models with interaction terms for race-ethnicity and income. RESULTS: For each perinatal time point, all categories of racial-ethnic minority women experienced higher rates of uninsurance than white non-Hispanic women. From preconception to postpartum, 75.3% (95% CI 74.7-75.8) of white non-Hispanic women had continuous insurance compared with 55.4% of black non-Hispanic women (95% CI 54.2-56.6), 49.9% of indigenous women (95% CI 46.8-53.0) and 20.5% of Hispanic Spanish-speaking women (95% CI 18.9-22.2). In adjusted models, lower-income Hispanic women and indigenous women had a significantly higher predicted probability of uninsurance in the preconception and postpartum period compared with white non-Hispanic women. CONCLUSION: Disruptions in perinatal insurance coverage disproportionately affect indigenous, Hispanic, and black non-Hispanic women. Differential insurance coverage may have important implications for racial-ethnic disparities in access to perinatal care and maternal-infant health.

Out-Of-Pocket Spending For Maternity Care Among Women With Employer-Based Insurance, 2008-15.

The Affordable Care Act (ACA) requires employer-based insurance plans to cover maternity services, but plans are allowed to impose cost sharing such as copayments and deductibles for these services. This study aimed to evaluate trends in cost sharing for maternity care among working women in employer-based plans, before and after the ACA. Our data indicate that between 2008 and 2015, average out-of-pocket spending for maternity care rose among women with employer-based insurance. This increase was largely driven by increased spending among women with deductibles. When we controlled for potential confounders, we found that out-of-pocket spending was higher for lower-income working women in 2008-13, but disparities disappeared in 2014-15 because of a continued rise in spending among higher-income working women. Policies that aim to lower out-of-pocket spending for maternity care could reduce a significant financial burden on families.

Defining "normal recovery" of pelvic floor function and appearance in a high-risk vaginal delivery cohort.

INTRODUCTION AND HYPOTHESIS: Childbirth pelvic floor trauma leads to pelvic floor disorders. Identification of significant injuries would facilitate intervention for recovery. Our objectives were to identify differences in pelvic floor appearance and function following delivery and patterns of normal recovery in women sustaining high-risk labor events. METHODS: We completed a prospective cohort study comparing women undergoing vaginal births involving risk factors for pelvic floor injury with women undergoing cesareans. Data were collected on multidimensional factors including levator ani muscle (LA) tears. Descriptive and bivariate statistics were used to compare the groups. We identified potential markers of pelvic floor injury based on effect size. RESULTS: Eighty-two women post-vaginal delivery and 30 women post-cesarean enrolled. The vaginal group had decreased perineal body length between early postpartum, 6 weeks (p < 0.001), and 6 months (p = 0.001). POP-Q points did not change between any time point (all p > 0.05). Measures of strength improved between each time point (all p < 0.002). When compared with cesarean delivery, women post-vaginal birth had longer genital hiatus and lower anterior and posterior vaginal walls (all p < 0.05). Based on theoretical considerations and effect sizes, those with Bp ≥0 cm, Kegel force ≤1.50 N, and/or an LA tear on imaging were considered to have significant pelvic floor injury. Using this definition, at 6 weeks, 27 (46.4%) women were classified as injured. At 6 months, 13 (29.6%) remained injured. CONCLUSIONS: We propose that pelvic floor muscle strength, posterior vaginal wall support, and imaging consistent with LA tear are potential indicators of abnormal or prolonged recovery in this cohort with high-risk labor events.

Cost Sharing and Utilization of Postpartum Intrauterine Devices and Contraceptive Implants Among Commercially Insured Women.

BACKGROUND: Cost sharing may impede postpartum contraceptive use. We evaluated the association between out-of-pocket costs and long-acting reversible contraceptive (LARC) insertion among commercially insured postpartum women. METHODS: Using the Clinformatics Data Mart, we examined out-of-pocket costs for LARC insertions at 0 to 3 and 4-60 days postpartum among women in employer-sponsored health plans from 2013 to 2016. Patient costs were estimated by summing copayment, coinsurance, and deductible payments for LARC services (device + placement). Multivariable logistic regression evaluated the association between plan cost sharing for LARC services (at least one beneficiary with >$200 cost share) and LARC insertion by 60 days postpartum (yes/no). RESULTS: We identified 396,073 deliveries among women in 51,797 employer-based plans. Overall, LARC placement by 60 days postpartum was observed after 5.2% (n = 20,604) of deliveries. Inpatient LARC insertion (n = 233; 0.06% of deliveries) was less common than outpatient LARC insertion (n = 20,375; 5.14% of deliveries). Cost sharing was observed in 23.4% of LARC insertions (inpatient IUD: median, $50.00; range, $0.93-5,055.91; inpatient implant: median, $11.91; range, $2.49-650.14; outpatient IUD: median, $25.00; range, $0.01-3,354.80; outpatient implant: median, $27.20; range, $0.18-2,444.01). Among 5,895 plans with at least one LARC insertion and after adjusting for patient age, poverty status, race/ethnicity, region, and plan type, women in plans with cost sharing of more than $200 demonstrated lower odds of LARC use by 60 days postpartum (odds ratio, 0.74; 95% confidence interval, 0.71-0.77). CONCLUSIONS: Cost sharing for postpartum LARC is associated with use, suggesting that out-of-pocket costs may impede LARC access for some commercially insured postpartum women. Reducing out-of-pocket costs for the most effective forms of contraception may increase use.

Comparison of measurement systems for posterior vaginal wall prolapse on magnetic resonance imaging.

INTRODUCTION AND HYPOTHESIS: A wide variety of reference lines and landmarks have been used in imaging studies to diagnose and quantify posterior vaginal wall prolapse without consensus. We sought to determine which is the best system to (1) identify posterior vaginal wall prolapse and its appropriate cutoff values and (2) assess the prolapse size. METHODS: This was a secondary analysis of sagittal maximal Valsalva dynamic MRI scans from 52 posterior-predominant prolapse cases and 60 comparable controls from ongoing research. All eight existing measurement lines and a new parameter, the exposed vaginal length, were measured. Expert opinions were used to score the prolapse sizes. Simple linear regressions, effect sizes, area under the curve, and classification and regression tree analyses were used to compare these reference systems and determine cutoff values. Linear and ordinal logistic regressions were used to assess the effectiveness of the prolapse size. RESULTS: Among existing parameters, "the perineal line-internal pubis," a reference line from the inside of the pubic symphysis to the front tip of the perineal body (cutoff value 0.9 cm), had the largest effect size (1.61), showed the highest sensitivity and specificity to discriminate prolapse with area under the curve (0.91), and explained the most variation (68%) in prolapse size scores. The exposed vaginal length (cutoff value 2.9) outperformed all the existing lines, with the largest effect size (2.09), area under the curve (0.95), and R-squared value (0.77). CONCLUSIONS: The exposed vaginal length performs slightly better than the best of the existing systems, for both diagnosing and quantifying posterior prolapse size. Performance characteristics and evidence-based cutoffs might be useful in clinical practice.