Estimates of use of preferred contraceptive method in the United States: a population-based study.

Background: In the U.S. and globally, dominant metrics of contraceptive access focus on the use of certain contraceptive methods and do not address self-defined need for contraception; therefore, these metrics fail to attend to person-centeredness, a key component of healthcare quality. This study addresses this gap by presenting new data from the U.S. on preferred contraceptive method use, a person-centered contraceptive access indicator. Additionally, we examine the association between key aspects of person-centered healthcare access and preferred contraceptive method use. Methods: We fielded a nationally representative survey in the U.S. in English and Spanish in 2022, surveying non-sterile 15-44-year-olds assigned female sex at birth. Among current and prospective contraceptive users (unweighted n = 2119), we describe preferred method use, reasons for non-use, and differences in preferred method use by sociodemographic characteristics. We conduct logistic regression analyses examining the association between four aspects of person-centered healthcare access and preferred contraceptive method use. Findings: A quarter (25.2%) of current and prospective users reported there was another method they would like to use, with oral contraception and vasectomy most selected. Reasons for non-use of preferred contraception included side effects (28.8%), sex-related reasons (25.1%), logistics/knowledge barriers (18.6%), safety concerns (18.3%), and cost (17.6%). In adjusted logistic regression analyses, respondents who felt they had enough information to choose appropriate contraception (Adjusted Odds Ratio [AOR] 3.31; 95% CI 2.10, 5.21), were very (AOR 9.24; 95% CI 4.29, 19.91) or somewhat confident (AOR 3.78; 95% CI 1.76, 8.12) they could obtain desired contraception, had received person-centered contraceptive counseling (AOR 1.72; 95% CI 1.33, 2.23), and had not experienced discrimination in family planning settings (AOR 1.58; 95% CI 1.13, 2.20) had increased odds of preferred contraceptive method use. Interpretation: An estimated 8.1 million individuals in the U.S. are not using a preferred contraceptive method. Interventions should focus on holistic, person-centered contraceptive access, given the implications of information, self-efficacy, and discriminatory care for preferred method use. Funding: Arnold Ventures.

Evaluating fertility preservation interventions for alignment with ASCO Guidelines for reproductive aged women undergoing cancer treatment: a systematic review.

PURPOSE: While cancer treatment advancements have increased the number of reproductive-aged women survivors, they can harm reproductive function. Despite national guidelines, oncofertility service uptake remains low. This review explores interventions for fertility preservation alignment with American Society of Clinical Oncology (ASCO) guidelines and consideration of a multilevel framework. METHODS: We systematically reviewed literature from 2006 to 2022 across four databases. Identified interventions were assessed and scored for quality based on CONSORT and TREND statement checklists. Results were synthesized to assess for intervention alignment with ASCO guidelines and four multilevel intervention framework characteristics: targeted levels of influence, conceptual clarity, methodologic pragmatism, and sustainability. RESULTS: Of 407 articles identified, this review includes nine unique interventions. The average quality score was 7.7 out of 11. No intervention was guided by theory. Per ASCO guidelines, most (n=8) interventions included provider-led discussions of treatment-impaired fertility. Fewer noted discussions on fertility preservation approaches (n=5) and specified discussion timing (n=4). Most (n=8) referred patients to reproductive specialists, and few (n=2) included psychosocial service referrals. Most (n=8) were multilevel, with five targeting three levels of influence. Despite targeting multiple levels, all analyses were conducted at the individual level. Intervention strategies included: educational components (n=5), decision aids (n=2), and nurse navigators (n=2). Five interventions considered stakeholders' views. All interventions were implemented in real-world contexts, and only three discussed sustainability. CONCLUSIONS: This review identifies key gaps in ASCO guideline-concordant fertility preservation that could be filled by updating and adhering to standardized clinical practice guidelines and considering multilevel implementation frameworks elements.

A qualitative analysis examining intersectional stigma among young adults living with HIV in Atlanta, Georgia.

HIV-related stigma is a barrier to engagement in care for young adults living with HIV. Other intersecting forms of stigma (e.g., racism, sexism, homophobia), may worsen HIV-related stigma and impact engagement in care. From November 2020 to February 2021, we conducted 20 in-depth qualitative interviews among young adults living with HIV attending a large, comprehensive HIV care center in Atlanta, Georgia. Semi-structured interview guides based on Earnshaw and Chaudoir's HIV Stigma Framework and the theory of intersectionality facilitated discussion around experiences with various forms of stigma and its possible influence on healthcare engagement. Using the social-ecological model, we used thematic analysis to contextualize how young adults living with HIV experienced intersectional stigma and enacted, anticipated, and internalized HIV stigma in both healthcare and non-healthcare settings. Most participants identified as male, Black/African American, and gay. Participants described stigma at intrapersonal, interpersonal, clinic, and community levels. Intrapersonal stigma was associated with delayed care seeking, isolation, and fear of disclosure. Interpersonal stigma included discrimination from family and friends and avoidance of close relationships to elude disclosure. At the clinic level, stigma included negative experiences with staff in HIV and non-HIV healthcare settings, which contributed to decreased engagement in care. Stigma in the community included differential treatment from employers, community leaders, and religious community and was associated with feelings of helplessness related to current societal inequalities. Coping/motivating mechanisms for stigma included prioritizing health, eliciting support from the medical care team and peers. Our findings show different intersecting stigmas are barriers to healthcare at multiple levels for young adults living with HIV, potentially exacerbating existing health and social disparities. To improve engagement in care among young adults living with HIV, future interventions should address the different mechanisms of stigma at community, clinic, interpersonal and intrapersonal levels by enhancing social support and improving healthcare structural competency.

Estimation of Multiyear Consequences for Abortion Access in Georgia Under a Law Limiting Abortion to Early Pregnancy.

Importance: Following the US Supreme Court ruling in Dobbs v Jackson Women's Health Organization, Georgia's law limiting abortion to early pregnancy, House Bill 481 (HB481), was allowed to go into effect in July 2022. Objectives: To estimate anticipated multiyear effects of HB481, which prohibits abortions after detection of embryonic cardiac activity, on abortion incidence in Georgia, and to examine inequities by race, age, and socioeconomic status. Design, Setting, and Participants: This repeated cross-sectional analysis used abortion surveillance data from January 1, 2007, to December 31, 2017, to estimate future effects of HB481 on abortion care in Georgia, with a focus on the 2 most recent years of data (2016 and 2017). Abortion surveillance data were obtained from the 2007-2017 Georgia Department of Public Health's Induced Termination of Pregnancy files. Linear regression was used to estimate trends in abortions provided at less than 6 weeks' gestation and at 6 weeks' gestation or later in Georgia, and χ2 analyses were used to compare group differences by race, age, and educational attainment. Data were analyzed from July 26 to September 22, 2022. Exposures: HB481, Georgia's law limiting abortion to early pregnancy. Main Outcome and Measures: Weeks' gestation at abortion (<6 vs ≥6 weeks). Results: From January 1, 2007, to December 31, 2017, there were 360 972 reported abortions in Georgia, with an annual mean (SD) of 32 816 (1812) abortions. Estimates from 2016 to 2017 suggest that 3854 abortions in Georgia (11.6%) would likely meet eligibility requirements for abortion care under HB481. Fewer abortions obtained by Black patients (1943 [9.6%] vs 1280 [16.2%] for White patients), patients younger than 20 years (261 [9.1%] vs 168 [15.0%] for those 40 years and older), and patients with fewer years of education (392 [9.2%] with less than a high school diploma and 1065 [9.6%] with a high school diploma vs 2395 [13.5%] for those with some college) would likely meet eligibility requirements under HB481. Conclusions and Relevance: These findings suggest that Georgia's law limiting abortion to early pregnancy (HB481) would eliminate access to abortion for nearly 90% of patients in Georgia, and disproportionately harm patients who are Black, younger, and in lower socioeconomic status groups.

Medication Abortion "Reversal" Laws: How Unsound Science Paved the Way for Dangerous Abortion Policy.

Objectives. To longitudinally examine the legal landscape of laws requiring abortion patients be informed about the possibility of medication abortion (MAB) "reversal" (in quotes as it does not refer to an evidence-based medical procedure). Methods. We collected legal data on enacted state MAB-reversal laws across all 50 US states and Washington, DC, (collectively, states) from 2012 through 2021. We descriptively analyzed these laws to identify legal variation over time and geography, and conducted a content analysis to identify qualitative themes and patterns in MAB-reversal laws. Results. As of 2021, 14 states (27%)-mostly in the midwestern and southern United States-have enacted MAB-reversal laws. States largely use explicit language to describe reversal, require patients receive information during preabortion counseling, require physicians or physicians' agents to inform patients, instruct patients to contact a health care provider or visit "abortion pill reversal" resources for more information, and require reversal information be posted on state-managed Web sites. Conclusions. Reversal laws continue a dangerous precedent of using unsound science to justify laws regulating abortion access, intrude upon the patient‒provider relationship, and may negatively affect the emotional and physical health of patients seeking an MAB. (Am J Public Health. 2023;113(2):202-212. https://doi.org/10.2105/AJPH.2022.307140).

Racial disparities in pregnancy options counseling and referral in the US South.

OBJECTIVE: The objective of this study is to examine racial variation in receipt of counseling and referral for pregnancy options (abortion, adoption, and parenting) following pregnancy confirmation. Equitable offering of such information is a professional and ethical obligation and an opportunity to prevent racial disparities in maternal and child health. DATA SOURCE: Primary data from patients at southern United States publicly funded family planning clinics, October 2018-June 2019. STUDY DESIGN: Patients at 14 clinics completed a survey about their experiences with pregnancy options counseling and referral following a positive pregnancy test. The primary predictor variable was patients' self-reported racial identity. Outcomes included discussion of pregnancy options, referral for those options, and for support services. DATA COLLECTION: Data from eligible patients with non-missing information for key variables (n = 313) were analyzed using descriptive statistics, χ2 tests, and multivariable logistic regression. PRINCIPAL FINDINGS: Patients were largely Black (58%), uninsured (64%), and 18-29 years of age (80%). Intention to continue pregnancy and receipt of prenatal care referral did not differ significantly among Black as compared to non-Black patients. However, Black patients had a higher likelihood of wanting an abortion or adoption referral and not receiving one (abortion: marginal effect [ME] = 7.68%, p = 0.037; adjusted ME [aME] = 9.02%, p = 0.015; adoption: ME = 7.06%, p = 0.031; aME = 8.42%, p = 0.011). Black patients intending to end their pregnancies had a lower probability of receiving an abortion referral than non-Black patients (ME = -22.37%, p = 0.004; aME = -19.69%, p = 0.023). In the fully adjusted model, Black patients also had a higher probability of wanting access to care resources (including transportation, childcare, and financial support) and not receiving them (aME = 5.38%, p = 0.019). CONCLUSIONS: Clinical interactions surrounding pregnancy confirmation provide critical opportunities to discuss options, coordinate care, and mitigate risk, yet are susceptible to systemic bias. These findings add to limited evidence around pregnancy counseling and referral disparities. Ongoing assessment of pregnancy counseling and referral disparities can provide insight into organizational strengths or the potential to increase structural equity.

"Doulas shouldn't be considered visitors, we should be considered a part of [the] team": doula care in Georgia, USA during the COVID-19 pandemic.

Doula support improves maternal-child health outcomes. However, during the COVID-19 pandemic, hospitals restricted the number of support people allowed during childbirth. An academic-community research team conducted 17 in-depth interviews and structured surveys with doulas in metro-Atlanta, Georgia, USA from November 2020 to January 2021. Surveys were analysed for descriptive statistics in Stata v. 14, and interviews were analysed in Dedoose using a codebook and memo-ing for thematic analysis. All 17 doulas reported COVID-19 changed their practices: most were unable to accompany clients to delivery (14), started using personal protective equipment (13), used virtual services (12), and had to limit the number of in-person prenatal/postpartum visits (11). Several attended more home births (6) because birthing people were afraid to have their babies in the hospital. Some stopped seeing clients altogether due to safety concerns (2). Many lost clientele who could no longer afford doula services, and some offered pro bono services. Most doulas pointed to restrictive hospital policies that excluded doulas and disallowed virtual support as they felt doulas should be considered a part of the team and clients should not be forced to decide between having their doula or their partner in the room. COVID-19 has severely impacted access to and provision of doula care, mostly due to economic hardship for clients and restrictive hospital policies. At the same time, doulas and their clients have been resourceful - using virtual technology, innovative payment models, and home births.

"I don't regret it at all. It's just I wish the process had a bit more humanity to it a bit more holistic": a qualitative, community-led medication abortion study with Black and Latinx Women in Georgia, USA.

Traditional family planning research has excluded Black and Latinx leaders, and little is known about medication abortion (MA) among racial/ethnic minorities, although it is an increasingly vital reproductive health service, particularly after the fall of Roe v. Wade. Reproductive justice (RJ) community-based organisation (CBO) SisterLove led a study on Black and Latinx women's MA perceptions and experiences in Georgia. From April 2019 to December 2020, we conducted key informant interviews with 20 abortion providers and CBO leaders and 32 in-depth interviews and 6 focus groups (n = 30) with Black and Latinx women. We analysed data thematically using a team-based, iterative approach of coding, memo-ing, and discussion. Participants described multilevel barriers to and strategies for MA access, wishing that "the process had a bit more humanity … [it] should be more holistic." Barriers included (1) sociocultural factors (intersectional oppression, intersectional stigma, and medical experimentation); (2) national and state policies; (3) clinic- and provider-related factors (lack of diverse clinic staff, long waiting times); and (4) individual-level factors (lack of knowledge and social support). Suggested solutions included (1) social media campaigns and story-sharing; (2) RJ-based policy advocacy; (3) diversifying clinic staff, offering flexible scheduling and fees, community integration of abortion, and RJ abortion funds; and (4) social support (including abortion doulas) and comprehensive sex education. Findings suggest that equitable MA access for Black and Latinx communities in the post-Roe era will require multi-level intervention, informed by community-led evidence production; holistic, de-medicalised, and human rights-based care models; and intersectional RJ policy advocacy.

"Post-Roe" Abortion Policy Context Heightens the Imperative for Multilevel, Comprehensive, Integrated Health Education.

The exceptionalism of abortion in public health education, due to social stigma, politicization, and lack of training, contributes to misinformation, policies unjustified by rigorous science, lack of access to person-centered health care, and systemic pregnancy-related inequities. Now that abortion access has vanished for large portions of the United States, following the Supreme Court decision in Dobbs v. Jackson Women's Health Organization (JWHO), health educators must work to eliminate abortion-related silos, destigmatize abortion education, and bring comprehensive sexual and reproductive health information and evidence to the many audiences that will require it. We discuss consequences of abortion exceptionalism in health education for the public, health care providers, pregnant people, and health professionals in training-and opportunities to better and more accessibly provide sexual and reproductive health education to these audiences.

Dispersion of contraceptive access policies across the United States from 2006 to 2021.

Person-centered contraceptive access benefits reproductive autonomy, sexual wellbeing, menstrual regulation, and other preventive health. However, contraceptive access varies by social and geographic position, with policies either perpetuating or alleviating health inequities. We describe geographic and time-trend variation in an index from fewer (less expansive) to greater (more expansive) aggregation of U.S. state-level contraceptive access policies across 50 states and Washington, D.C. (collectively, states) from 2006 to 2021. We collected data from primary and secondary sources on 23 policies regulating contraceptive education, insurance coverage, minor's rights, provider authority, and more. As of 2021, the most enacted policies expanded contraceptive access through: 1) prescribing authority for nurse practitioners, certified nurse-midwives (n = 50, 98 % of states), and clinical nurse specialists (n = 38, 75 %); 2) Medicaid expansion (n = 38, 75 %); 3) prescription method insurance coverage (n = 30, 59 %); and 4) dispensing authority for nurse practitioners and certified nurse-midwives (n = 29, 57 %). The average overall U.S. policy index value increased in expansiveness from 6.9 in 2006 to 8.6 in 2021. States in the West and Northeast regions had the most expansive contraceptive access landscapes (average index values of 9.0 and 8.2, respectively) and grew more expansive over time (increased by 4-5 policies). The Midwest and South had least expansive landscapes (average index values of 5.0 and 6.1, respectively). Regions with more expansive sexual and reproductive health policy environments further expanded access, whereas least expansive environments were maintained. More nuanced understanding of how contraceptive policy diffusion affects health outcomes and equity is needed to inform public health advocacy and law making.

Patient Health Literacy and Communication with Providers Among Women Living with HIV: A Mixed Methods Study.

In this mixed-methods study, we examine the relationship between provider communication and patient health literacy on HIV continuum of care outcomes among women living with HIV in the United States. We thematically coded qualitative data from focus groups and interviews (N = 92) and conducted mediation analyses with quantitative survey data (N = 1455) collected from Women's Interagency HIV Study participants. Four qualitative themes related to provider communication emerged: importance of respect and non-verbal cues; providers' expressions of condescension and judgement; patient health literacy; and unclear, insufficient provider communication resulting in diminished trust. Quantitative mediation analyses suggest that higher health literacy is associated with higher perceived patient-provider interaction quality, which in turn is associated with higher levels of trust in HIV providers, improved antiretroviral medication adherence, and reduced missed clinical visits. Findings indicate that enhancing provider communication and bolstering patient health literacy could have a positive impact on the HIV continuum of care.

RESUMEN: En este estudio de métodos mixtos, examinamos la relación entre la comunicación del proveedor y la alfabetización sanitaria del paciente sobre los resultados de la atención continua del VIH entre las mujeres que viven con el VIH en los Estados Unidos. Codificamos temáticamente datos cualitativos de grupos focales y entrevistas (N = 92) y realizamos análisis de mediación con datos de encuestas cuantitativas (N = 1455) recopilados de participantes del Estudio de VIH entre agencias de mujeres. Surgieron cuatro temas cualitativos relacionados con la comunicación con el proveedor: la importancia del respeto y las señales no verbales; las expresiones de condescendencia y juicio de los proveedores; alfabetización en salud del paciente; y una comunicación poco clara e insuficiente con el proveedor que da como resultado una disminución de la confianza. Los análisis de mediación cuantitativa sugieren que una mayor alfabetización en salud se asocia con una mayor calidad de interacción percibida entre el paciente y el proveedor, que a su vez se asocia con niveles más altos de confianza en los proveedores de VIH, una mejor adherencia a la medicación antirretroviral y una reducción de las visitas clínicas perdidas. Los resultados indican que mejorar la comunicación con los proveedores y reforzar la alfabetización sanitaria del paciente podría tener un impacto positivo en la atención continua del VIH.

Variation in Restrictive Abortion Policies and Adverse Birth Outcomes in the United States from 2005 to 2015.

BACKGROUND: Since 2011, U.S. states have enacted more than 400 policies restricting abortion access. As structural determinants, abortion policies have the potential to influence maternal and child health access, outcomes, and equity through multiple mechanisms. Limited research has examined their implications for birth outcomes. METHODS: We created a state-level abortion restrictiveness index composed of 18 restrictive abortion policies and evaluated the association between this index and individual-level probabilities of preterm birth (PTB) and low birthweight (LBW) within the United States and by Census Region, using data from the 2005-2015 National Center for Health Statistics Period Linked Live Birth-Infant Death Files. We used logistic multivariable regression modeling, adjusting for individual- and state-level factors and state and year fixed effects. RESULTS: Among 2,500,000 live births, 269,253 (12.0%) were PTBs and 182,960 (8.1%) were LBW. On average from 2005 to 2015, states had approximately seven restrictive abortion policies enacted, with more policies enacted in the Midwest and South. Nationally, relationships between state restrictiveness indices and adverse birth outcomes were insignificant. Regional analyses revealed that a 1 standard deviation increase in a state's restrictiveness index was associated with a 2% increase in PTB in the Midwest (marginal effect [ME], 0.25; 95% confidence interval [CI], 0.04-0.45; p < .01), a 15% increase in LBW in the Northeast (ME, 1.24; 95% CI, 0.12-2.35; p < .05), and a 2% increase in LBW in the West (ME, 0.12; 95% CI, 0.01-0.25; p < .05). CONCLUSION: Variation in restrictive abortion policy environments may have downstream implications for birth outcomes, and increases in abortion restrictions were associated with adverse birth outcomes in three out of four Census Regions.

Racial/ethnic and educational inequities in restrictive abortion policy variation and adverse birth outcomes in the United States.

BACKGROUND: To examine racial/ethnic and educational inequities in the relationship between state-level restrictive abortion policies and adverse birth outcomes from 2005 to 2015 in the United States. METHODS: Using a state-level abortion restrictiveness index comprised of 18 restrictive abortion policies, we conducted a retrospective longitudinal analysis examining whether race/ethnicity and education level moderated the relationship between the restrictiveness index and individual-level probabilities of preterm birth (PTB) and low birthweight (LBW). Data were obtained from the 2005-2015 National Center for Health Statistics Period Linked Live Birth-Infant Death Files and analyzed with linear probability models adjusted for individual- and state-level characteristics and state and year fixed-effects. RESULTS: Among 2,250,000 live births, 269,253 (12.0%) were PTBs and 182,960 (8.1%) were LBW. On average, states had approximately seven restrictive abortion policies enacted from 2005 to 2015. Black individuals experienced increased probability of PTB with additional exposure to restrictive abortion policies compared to non-Black individuals. Similarly, those with less than a college degree experienced increased probability of LBW with additional exposure to restrictive abortion policies compared to college graduates. For all analyses, inequities worsened as state environments grew increasingly restrictive. CONCLUSION: Findings demonstrate that Black individuals at all educational levels and those with fewer years of education disproportionately experienced adverse birth outcomes associated with restrictive abortion policies. Restrictive abortion policies may compound existing racial/ethnic, socioeconomic, and intersecting racial/ethnic and socioeconomic perinatal and infant health inequities.

Sociodemographic and Service Use Characteristics of Abortion Fund Cases from Six States in the U.S. Southeast.

Abortion funds are key actors in mitigating barriers to abortion access, particularly in contexts where state-level abortion access restrictions are concentrated. Using 2017-2019 case management data from a regional abortion fund in the southeastern U.S., we described the sociodemographic and service use characteristics of cases overall (n = 9585) and stratified by state of residence (Alabama, Florida, Georgia, Mississippi, South Carolina, and Tennessee). Overall, cases represented people seeking abortion fund assistance who predominately identified as non-Hispanic Black (81%), 18-34 years of age (84%), publicly or uninsured (87%), having completed a high school degree or some college (70%), having one or more children (77%), and as Christian (58%). Most cases involved an in-state clinic (81%), clinic travel distance under 50 miles (63%), surgical abortion (66%), and pregnancy under 13 weeks' gestation (73%), with variation across states. The median abortion fund contribution pledge was $75 (interquartile range (IQR): 60-100), supplementing median caller contributions of $200 (IQR: 40-300). These data provide a unique snapshot of a population navigating disproportionate, intersecting barriers to abortion access, and abortion fund capacity for social care and science. Findings can inform abortion fund development, data quality improvement efforts, as well as reproductive health, rights and justice advocacy, policy, and research.

How Can the Experiences of Black Women Living With HIV Inform Equitable and Respectful Reproductive Health Care Delivery?

Black women living with HIV (BWLWH) contend with injuries of injustice, which manifest in restricted reproductive autonomy and decision-making power in social and medical settings. Mitigating threats to reproductive autonomy calls for innovations that consider patients' needs and offer insights on how historically situated marginalization influences today's institutional, political, and economic systems and shapes reproductive decision making. In addition to cross-disciplinary expertise and collaboration, integrating structural competency into reproductive health care requires demonstrating respect for the autonomy, lived experiences, and preferences of BWLWH.

Resilience and HIV Treatment Outcomes Among Women Living with HIV in the United States: A Mixed-Methods Analysis.

Resilience is defined as the ability and process to transform adversity into opportunities for growth and adaptation. Resilience may be especially important for people living with HIV (PLWH), who are susceptible to anxiety and depressive disorders, which are commonly linked to risk behaviors (i.e., alcohol and drug abuse), poor adherence to medical regimens, increased risk of morbidity and mortality, and related stigma and discrimination. To date, few studies have examined the impact of resilience on health-related behaviors and outcomes among PLWH, particularly among minority women living with HIV (WLWH) who are dealing with multiple stressors impacting their health. This study used a convergent parallel mixed-methods design to collect, analyze, and integrate qualitative and quantitative data from a subsample of WLWH enrolled in the Women's Interagency HIV Study (WIHS). The aims of the study were to (1) qualitatively examine the resilience perspectives of 76 marginalized WLWH, and; (2) quantitatively assess the associations of resilience with HIV health outcomes-adherence to antiretroviral therapy and viral suppression-in the context of differing levels of internalized HIV-related stigma and depressive symptoms (n = 420). Findings from this mixed-methods study suggest that resilience is an important resource that can aid WLWH in coping constructively with adversity by capitalizing on intrapersonal traits and states, interpersonal and institutional resources, and spiritual and/or religious practices. Given the complex medical and social needs of marginalized WLWH, intervention strategies should focus on mitigating psychosocial burdens of stigma and depression, in addition to building resilience.

Abortion attitudes, religious and moral beliefs, and pastoral care among Protestant religious leaders in Georgia.

OBJECTIVE: The purpose of this study is to explore Protestant religious leaders' attitudes towards abortion and their strategies for pastoral care in Georgia, USA. Religious leaders may play an important role in providing sexual and reproductive health pastoral care given a long history of supporting healing and health promotion. METHODS: We conducted 20 in-depth interviews with Mainline and Black Protestant religious leaders on their attitudes toward abortion and how they provide pastoral care for abortion. The study was conducted in a county with relatively higher rates of abortion, lower access to sexual and reproductive health services, higher religiosity, and greater denominational diversity compared to other counties in the state. Interviews were audio-recorded, transcribed verbatim, and analyzed by thematic analysis. RESULTS: Religious leaders' attitudes towards abortion fell on a spectrum from "pro-life" to "pro-choice". However, most participants expressed attitudes in the middle of this spectrum and described more nuanced, complex, and sometimes contradictory views. Differences in abortion attitudes stemmed from varying beliefs on when life begins and circumstances in which abortion may be morally acceptable. Religious leaders described their pastoral care on abortion as "journeying with" congregants by advising them to make well-informed decisions irrespective of the religious leader's own attitudes. However, many religious leaders described a lack of preparation and training to have these conversations. Leaders emphasized not condoning abortion, yet being willing to emotionally support women because spiritual leaders are compelled to love and provide pastoral care. Paradoxically, all leaders emphasized the importance of empathy and compassion for people who have unplanned pregnancies, yet only leaders whose attitudes were "pro-choice" or in the middle of the spectrum expressed an obligation to confront stigmatizing attitudes and behaviors towards people who experience abortion. Additionally, many leaders offer misinformation about abortion when offering pastoral care. CONCLUSION: These findings contribute to limited empirical evidence on pastoral care for abortion. We found religious leaders hold diverse attitudes and beliefs about abortion, rooted in Christian scripture and doctrine that inform advice and recommendations to congregants. While religious leaders may have formal training on pastoral care in general or theological education on the ethical issues related to abortion, they struggle to integrate their knowledge and training across these two areas. Still, leaders could be potentially important resources for empathy, compassion, and affirmation of agency in abortion decision-making, particularly in the Southern United States.

Quality of care for Black and Latina women living with HIV in the U.S.: a qualitative study.

BACKGROUND: Ending the HIV epidemic requires that women living with HIV (WLWH) have access to structurally competent HIV-related and other health care. WLWH may not regularly engage in care due to inadequate quality; however, women's perspectives on the quality of care they receive are understudied. METHODS: We conducted 12 focus groups and three in-depth interviews with Black (90%) and Latina (11%) WLWH enrolled in the Women's Interagency HIV Study in Atlanta, GA, Birmingham, AL, Brooklyn, NY, Chapel Hill, NC, Chicago, IL, and Jackson, MS from November 2017 to May 2018 (n = 92). We used a semi-structured format to facilitate discussions about satisfaction and dissatisfaction with health care engagement experiences, and suggestions for improvement, which were audio-recorded, transcribed, and coded using thematic analysis. RESULTS: Themes emerged related to women's health care satisfaction or dissatisfaction at the provider, clinic, and systems levels and across Institute of Medicine-defined quality of care domains (effectiveness, efficiency, equity, patient-centeredness, safety and timeliness). Women's degree of care satisfaction was driven by: 1) knowledge-based care resulting in desired outcomes (effectiveness); 2) coordination, continuity and necessity of care (efficiency); 3) perceived disparities in care (equity); 4) care delivery characterized by compassion, nonjudgment, accommodation, and autonomous decision-making (patient-centeredness); 5) attention to avoiding side effects and over-medicalization (safety); and 6) limited wait time (timeliness). CONCLUSIONS: Quality of care represents a key changeable lever affecting engage in care among WLWH. The communities most proximally affected by HIV should be key stakeholders in HIV-related quality assurance. Findings highlight aspects of the health care experience valued by WLWH, and potential participatory, patient-driven avenues for improvement.

The weathering hypothesis and stillbirth: racial disparities across the life span.

Objective: Given that studies have consistently demonstrated increased risk of stillbirth with increasing maternal age as well as race-ethnic disparities in stillbirth, the primary research question is how stillbirth risks within and between race-ethnic groups change with age.Design: Using fetal death (stillbirth) and live birth data from the National Center for Health Statistics 2007-2014. We calculated crude stillbirth rates (per 1,000 deliveries). Using multivariable logistic regression, we calculated adjusted odds ratios (aOR) and 95% confidence intervals (CI) for stillbirth across age groups to examine disparities in stillbirth among non-Hispanic blacks (blacks) and non-Hispanic whites (whites).Results: Rates and risks of stillbirth increased as maternal age increased; however, the magnitude of risk varies by race-ethnicity. Compared to women less than 20, black women age 40+ had a risk of almost 3.5 times (aOR = 3.47, 95% CI = 3.24-3.70) whereas among white women age 40+, the risk was more than 2.5 times (aOR = 2.68, 95% CI = 2.55-2.82). The risk of stillbirth among blacks compared to whites increased, peaking at ages 30-34 (aOR = 2.64, 95% CI = 2.56-2.73). At age 35 and beyond, the disparity in risks declined.Conclusion: As age increased, the risk of stillbirth increased for both blacks and whites. Because the disparity in risk between blacks and whites did not continue to increase with age, stillbirth does not seem to reflect the weathering hypothesis as other perinatal outcomes do.

Ethical Challenges and Lessons Learned from Qualitative Research with Low-Income African American Women Living with HIV in the South.

African American women living with HIV (WLWH) in the U.S. South encounter heightened marginalization due to the complex intersections of race, gender, poverty, and HIV status. Social vulnerabilities experienced by individuals and communities in daily life have the potential to sharpen ethical tensions in the context of research. Thus, conducting ethical research requires attention to the contextual challenges and concerns of diverse research populations to tailor participant protections to a particular sociocultural context. Using principles from the Belmont Report, the present report draws on data from a qualitative study with 42 African American WLWH in the South by highlighting the first author's accounts of ethical challenges that emerged during data collection. Findings suggest that engaging participants in their natural environments can inform the development of ethical research strategies germane to women's lived experiences. Study findings also contribute to empirical guidance for investigators engaging marginalized populations in scientific research.