Medicaid Payment For Postpartum Long-Acting Reversible Contraception Prompts More Equitable Use.

To increase access to highly effective contraception and improve reproductive autonomy, a growing number of state Medicaid programs pay for the provision of immediate postpartum long-acting reversible contraception (LARC) in addition to providing a global payment for maternity care. Using Pregnancy Risk Assessment Monitoring System data, we examined postpartum LARC use both overall and by race and ethnicity among respondents with Medicaid-paid births during the period 2012-18 in eight states that implemented immediate postpartum LARC payment and eight states without it. Using a quasi-experimental difference-in-differences design, we found that the policy resulted in an overall 2.1-percentage-point increase in postpartum LARC use. Our triple-differences analysis found no significant change among White mothers and a 3.7-percentage-point increase in use among Black mothers compared with White mothers. Additional research is needed to determine whether this increase was aligned with patients' preferences and whether hospitals' immediate postpartum LARC policies and practices take a patient-centered approach that supports reproductive autonomy and equity.

Building Blocks for the Long-acting and Permanent Contraceptives Coordinated Registry Network.

Objectives: A multistakeholder expert group under the Women's Health Technology Coordinated Registry Network (WHT-CRN) was organized to develop the foundation for national infrastructure capturing the performance of long-acting and permanent contraceptives. The group, consisting of representatives from professional societies, the US Food and Drug Administration, academia, industry and the patient community, was assembled to discuss the role and feasibility of the CRN and to identify the core data elements needed to assess contraceptive medical product technologies. Design: We applied a Delphi survey method approach to achieve consensus on a core minimum data set for the future CRN. A series of surveys were sent to the panel and answered by each expert anonymously and individually. Results from the surveys were collected, collated and analyzed by a study design team from Weill Cornell Medicine. After the first survey, questions for subsequent surveys were based on the analysis process and conference call discussions with group members. This process was repeated two times over a 6-month time period until consensus was achieved. Results: Twenty-three experts participated in the Delphi process. Participation rates in the first and second round of the Delphi survey were 83% and 100%, respectively. The working group reached final consensus on 121 core data elements capturing reproductive/gynecological history, surgical history, general medical history, encounter information, long-acting/permanent contraceptive index procedures and follow-up, procedures performed in conjunction with the index procedure, product removal, medications, complications related to the long-acting and/or permanent contraceptive procedure, pregnancy and evaluation of safety and effectiveness outcomes. Conclusions: The WHT-CRN expert group produced a consensus-based core set of data elements that allow the study of current and future contraceptives. These data elements influence patient and provider decisions about treatments and include important outcomes related to safety and effectiveness of these medical devices, which may benefit other women's health stakeholders.

Provision of fertility services to women in same-sex relationships at Catholic and non-Catholic clinics in the United States.

INTRODUCTION: This study addressed deficient information on the provision of infertility care in obstetrics and gynecology clinics. We additionally evaluated the availability of these services based on clinic affiliations or stated sexual orientation. METHODOLOGY: We performed a national cross-sectional "mystery caller" survey of 293 general obstetrics and gynecology clinics in 2017-2018. We matched clinics identified by web-based search engine in a 1:1 ratio by Catholic hospital affiliation, after determining number of clinics based on state-population densities. A standard call script included questions regarding provision of infertility services, ovulation induction methods, and information about the caller's sexual orientation. We performed descriptive frequencies and compared responses based on hospital affiliations. RESULTS: Of the 293 clinics included, 49% were affiliated with Catholic and 17% with academic hospitals. The majority offered infertility care (85%, 248/293), and of these 97% (240/248) offered ovulation induction. Only 3% (6/240) reported they would not provide to women in same-sex relationships. Most clinics not offering infertility evaluations (43/45, 96%) cited it was outside of their scope of care and of these 33% (15/45) did not provide information for self-referral. Clinics affiliated with academic (aOR 0.23) or Catholic (aOR 0.34) hospitals were less likely to provide evaluations. Those with academic affiliation were more likely to provide information for self-referral (aOR 19.2). DISCUSSION: Most general obstetrics and gynecology practices offered appointments for infertility evaluation and ovulation induction. Clinics rarely denied services to women reporting a same-sex partnership, regardless of hospital affiliation. These findings provide reassurance to same-sex couples seeking fertility care.

Work-arounds at faith-based obstetrics and gynecology residency programs to accomplish family planning training.

OBJECTIVE: To explore work-arounds at faith-based obstetrics and gynecology residency programs to accomplish family planning training. STUDY DESIGN: We invited educational stakeholders to participate in telephone interviews that elicited strategies for overcoming barriers to family planning training in religious settings. RESULTS: Eighteen out of 30 invited programs leaders participated. Work-arounds included reliance on non-contraceptive indications for contraception and permanent contraception provision, obtaining ethics committee approvals for service provision, and developing partnerships with offsite centers for training. CONCLUSION: Ob-gyn residency programs affiliated with religious hospitals utilize various work-arounds for family planning training and patient care. These findings may inform other programs that face similar barriers, secondary to institutional or governmental restrictions.

Concordance of Desired and Administered Postpartum Contraceptives among Emergency and Full Scope Medicaid Patients.

OBJECTIVE: To determine if concordance of contraceptive preference and uptake differ between postpartum recipients of emergency versus full scope Medicaid. STUDY DESIGN: We performed a historical cohort study of patients who delivered at a safety-net hospital in Denver, Colorado in 2016. In our public system, all patients had access to immediate postpartum tubal ligation and all forms of reversible contraception in outpatient clinics. We used data from electronic health records to compare contraceptive preferences and uptake between patients with full scope and emergency Medicaid at hospital discharge and by 12 weeks postpartum. We then compared contraceptive concordance (use of the same method as desired during delivery admission) between the groups at time of postpartum discharge and by 12 weeks postpartum. RESULTS: We examined 693 women; 349 (50.1%) had emergency Medicaid and 344 (49.9%) had full scope Medicaid. The mean age at delivery was 27.9 years, and most patients were Hispanic (74%). Women with emergency Medicaid were less likely to receive their desired method of postpartum contraception before hospital discharge (53.6% vs. 66.9%; p < .01). One-half of the patients with emergency Medicaid who did not receive their desired method of immediate postpartum contraception were unable to obtain it based on insurance ineligibility. By 12 weeks postpartum, the rates of concordance did not differ by insurance status: 52.4% of patients with emergency Medicaid and 55.2% of patients with full scope Medicaid received their desired method of contraception (p = .46). CONCLUSIONS: Emergency Medicaid recipients, largely recent and/or unauthorized immigrants, have high demand for highly effective postpartum contraceptives. Although emergency Medicaid recipients initially had lower rates of receipt of their desired contraceptive during the hospital stay compared with those with full scope Medicaid, they ultimately had similar concordance rates by 12 weeks postpartum. We suspect this finding was in part due to free access to all methods of contraception in our outpatient clinics during the postpartum course. Systemic barriers should be reduced to ensure better access to postpartum contraceptives for all patients, regardless of insurance coverage, to improve reproductive equity.

Assessing adverse event reports of hysteroscopic sterilization device removal using natural language processing.

OBJECTIVE: To develop an annotation model to apply natural language processing (NLP) to device adverse event reports and implement the model to evaluate the most frequently experienced events among women reporting a sterilization device removal. METHODS: We included adverse event reports from the Manufacturer and User Facility Device Experience database from January 2005 to June 2018 related to device removal following hysteroscopic sterilization. We used an iterative process to develop an annotation model that extracts six categories of desired information and applied the annotation model to train an NLP algorithm. We assessed the model performance using positive predictive value (PPV, also known as precision), sensitivity (also known as recall), and F1 score (a combined measure of PPV and sensitivity). Using extracted variables, we summarized the reporting source, the presence of prespecified and other patient and device events, additional sterilizations and other procedures performed, and time from implantation to removal. RESULTS: The overall F1 score was 91.5% for labeled items and 93.9% for distinct events after excluding duplicates. A total of 16 535 reports of device removal were analyzed. The most frequently reported patient and device events were abdominal/pelvic/genital pain (N = 13 166, 79.6%) and device dislocation/migration (N = 3180, 19.2%), respectively. Of those reporting an additional sterilization procedure, the majority had a hysterectomy or salpingectomy (N = 7932). One-fifth of the cases that had device removal timing specified reported a removal after 7 years following implantation (N = 2444/11 293). CONCLUSIONS: We present a roadmap to develop an annotation model for NLP to analyze device adverse event reports. The extracted information is informative and complements findings from previous research using administrative data.

Influence of a values clarification workshop on residents training at Catholic Hospital programs.

OBJECTIVES: To evaluate if a values clarification workshop conducted at Catholic hospital training programs influenced obstetrics and gynecology residents' abortion attitudes. STUDY DESIGN: Between 2018 and 2019, we provided a values clarification workshop focused on abortion care to 47 obstetrics and gynecology residents at five Catholic programs that do not provide abortion training. Participants received a pre-survey eliciting participant characteristics, and training experiences. On pre- and post-surveys, we asked participants to respond to abortion scenarios using a five-point Likert scales (1 = strongly disagree, 2 = somewhat disagree 3 = neither agree nor disagree, 4 = somewhat agree, 5 = strongly agree). We calculated descriptive frequencies, report the proportions agreeing with the statements (Likert ≥ 4) before and after the workshop, and compared median Likert responses using Wilcoxon matched pair test. RESULTS: Forty-one participants (87%) completed both surveys. Twelve (29%) reported Catholic religion, six (15%) reported their personal reproductive care views were in line with their institution, and five (12%) selected their program based on its religious affiliation. Three (9%) had experience with first-trimester abortion for nonmedical reasons, and 20 (49%) planned to provide such care after graduation. Both before and after the workshop, all participants could think of a justification why a patient with an undesired pregnancy would choose abortion. After the workshop, more residents were able to think of a justifiable reason for the following abortion-related scenarios: (1) patients declining post-abortal contraception (51% vs. 78%, p < 0.001), (2) patients presenting for subsequent abortion (93% vs 95%, p = 0.01), and (3) patients presenting for second-trimester abortion (93% vs. 100%, p = 0.001). Many participants increased their Likert score when asked about acceptability of patients declining post-abortal contraception (n = 24, 59%), patients seeking a subsequent abortion (n = 15, 37%), and patients obtaining a second trimester abortion contraception (n = 11, 27%). Emotional and professional reactions to these scenarios were unchanged. After the workshop, residents were more likely to consider either financial inability (73% vs. 83%, p < 0.01) or disruption to career or education (71% vs 80%, p < 0.01) as morally acceptable reasons for requesting an abortion. For abortion for a patient who is financially unable to support their child, 12 (29%) increased their Likert score, 1 (2%) had a lower score and the remaining 28 (68%) had no change. For abortion for a patient whose career or education would be disrupted 13 (32%) increased their Likert score, one (2%) had a lower score and the remaining 27 (66%) had no change. CONCLUSION: Our values clarification workshop resulted in more residents at Catholic training programs endorsing accepting attitudes toward abortion patient scenarios. Values clarification exercises can be a useful tool for residents to discuss abortion care, especially when training is insufficient. IMPLICATIONS: Most obstetrics and gynecology residents at Catholic hospitals experience limited training in abortion care. A values clarification workshop conducted at such programs may result in increasing resident acceptance of abortion-related patient care scenarios and may help reduce abortion stigma.

Identification of obstetric anal sphincter injuries (OASIs) and other lacerations: a national survey of nurse-midwives.

INTRODUCTION AND HYPOTHESIS: Clinical quality improvement relies on accurate understanding of current practice. We performed a cross-sectional national survey of certified nurse-midwives (CNMs) assessing classification and identification of obstetric anal sphincter injury (OASI) and other delivery lacerations. We hypothesized laceration diagnoses are frequently inaccurate, and delivery records for obstetric lacerations may be of questionable quality. METHODS: We emailed 6909 American College of Nurse Midwives members an internet-based survey link. Of respondents, we included clinically active CNMs who perform at least one delivery per month. We evaluated laceration knowledge and application using standard descriptive text and images and asked about processes for recording lacerations in the delivery record. RESULTS: We received 1070 (15.5%) completed surveys and 832 (77.8%) met inclusion criteria. Over 50% characterized their OASI training and ability to identify OASI as good/excellent. Most (79%) had never attended education review on OASI. The overall accuracy for classification and identification of perineal lacerations ranged from 49 to 99%. Non-perineal lacerations were frequently categorized using the perineal/OASI system. Half of respondents (51%) document their deliveries in an electronic medical record but a quarter (28%) are not personally responsible for approving delivery data. Younger participants without a doctoral degree, with self-assessed good/excellent laceration training, and caring for < 50% publicly insured patients had higher accuracy for laceration identification and diagnosis. CONCLUSIONS: We found high rates of inaccurate laceration diagnosis and inappropriate application of the perineal OASI degree system, suggesting education and training are needed. Clinical studies that rely on delivery diagnosis of OASI may not be reliable.

Integration of Catholic Values and Professional Obligations in the Provision of Family Planning Services: A Qualitative Study.

Importance: Religious leaders of the Catholic church created guidelines for practicing medicine, that involve reproductive care restrictions that may conflict with professional obligations. Objective: To explore how Catholic obstetrician-gynecologists integrate their religious values and professional obligations related to family planning services. Design, Setting, and Participants: In this qualitative investigation, in 2018, US-based obstetrician-gynecologists were recruited through an online survey and were invited to participate in audio-recorded telephone interviews using a semistructured interview guide. Participants were obstetrician-gynecologists who self-identified as Catholic and reported providing reproductive health care as follows: (1) provide natural family planning only (low practitioners), (2) provide additional contraceptive methods (moderate practitioners), and (3) provide family planning services including abortion (high practitioners). The study purposively sampled those with higher self-reported religiosity. Data were analyzed from November 2018 to February 2019. Main Outcomes and Measures: The primary outcome was understanding how participants describe integration of Catholic values with family planning service provision. The telephone interviews explored their integration of Catholic values and professional obligations, and 3 coders analyzed the responses using grounded theory. Results: Among the 34 Catholic obstetrician-gynecologists interviewed (27 women [79.4%]), there were 10 low, 15 moderate, and 9 high practitioners from 19 states. Participants' description of morality was consistent with Albert Bandura's Social-Cognitive Theory of Moral Thought and Action. The findings were used to create a modified framework. Within each group of physicians, 3 themes demonstrating their reconciliations between Catholic values and professional obligations emerged; each of these themes reflected one of the medical ethical principles of autonomy, beneficence, nonmaleficence, or justice. All 10 low practitioners primarily promoted natural family planning approaches to avoid iatrogenic risks and none provided abortion, reflecting nonmaleficence. Alternatively, moderate practitioners focused on nonmaleficence by offering contraception to prevent abortions. High practitioners primarily promoted patient autonomy by separating religious doctrine from medical practice. All had concerns for beneficence. In each group, 1 of the 4 medical ethical principles was underrepresented. Conclusions and Relevance: In this qualitative analysis, Catholic obstetrician-gynecologists establish their family planning care provision practices by emphasizing certain moral and/or ethical principles over others. These findings highlight how physician morality in the realm of family planning service provision often involves certain religious and/or professional reconciliations. Understanding the dilemmas Catholic obstetrician-gynecologists face can guide professional development efforts and inform ongoing discussions about conscientious objection and provision.

Association of a Pediatric Gynecology eLearning Module With Resident Knowledge and Clinical Skills: A Randomized Controlled Trial.

OBJECTIVE: To assess whether a pediatric and adolescent gynecology electronic learning (eLearning) module improves knowledge and clinical performance among obstetrics and gynecology residents. METHODS: We conducted a multi-institutional, single-blinded, randomized controlled trial across four university programs; three had pediatric and adolescent gynecology rotations, and two had pediatric and adolescent gynecology fellowship-trained faculty. Applying permutated block randomization, residents were randomized to no intervention or completion of a validated eLearning module on prepubertal bleeding. All residents subsequently completed a pediatric and adolescent gynecology-related knowledge assessment that queried understanding of prepubertal bleeding and an objective structured clinical examination that assessed history collection, performance of a prepubertal genital examination, vaginal culture, and vaginoscopy for a pediatric patient. Objective structured clinical examinations were videotaped and reviewed by two faculty, blinded to randomization group; interrater reliability score was 97%. We calculated descriptive frequencies and compared randomization groups using χ analyses and Fisher exact tests for categorical variables, and median tests for continuous variables; a value of P<.05 was considered significant. RESULTS: From July 2018 to June 2019, we invited 115 residents to participate; 97 (83%) completed both objective structured clinical examination and follow-up knowledge assessments. Most were female (91%) and the majority reported limited pediatric and adolescent gynecology didactic or clinical experience, with 36% reporting prior didactics on prepubertal vaginal bleeding and 33% reporting prior exposure to the prepubertal genital examination. Forty-five participants (46%) were randomized to the module and groups were similar across training levels. Residents assigned to the module scored significantly higher on the knowledge assessment (4/5 vs 2/5, P<.001) and objective structured clinical examination (13/16 vs 7/16, P<.001) and were more likely to avoid a speculum in the examination of a pediatric patient (95.6% vs 57.7%, P<.001). CONCLUSION: Our pediatric and adolescent gynecology eLearning module resulted in improved short-term resident knowledge and simulated clinical skills among obstetrics and gynecology residents. Applying this learning technique in other programs may help address deficiencies in pediatric and adolescent gynecology education and training.

Satisfaction with medication abortion and marijuana use: A prospective cohort study.

OBJECTIVES: This exploratory study compared self-reported satisfaction rates and pain scores between patients who used marijuana during their medication abortion versus non-users. STUDY DESIGN: We recruited medication abortion patients at a University-affiliated abortion clinic in Denver, Colorado. Participants completed a pre-abortion questionnaire, pain diary, and follow-up survey that assessed satisfaction with pain control, symptoms, and abortion experience. Using medians test, we compared the sums of median satisfaction scores between patients who used marijuana versus non-users. Based on diary entries, we also compared reported pain over 24 h after misoprostol (area under the curve [AUC]) between cohorts. RESULTS: We enrolled 51 participants; 16 marijuana users and 35 non-marijuana users. Marijuana users and non-users had similar sums of median satisfaction scores (22 vs. 20 out of 30, p = 0.90) and median question-specific satisfaction scores (range 7-8 vs. 6.5-8, p = 0.6-1.0). Sixteen marijuana users (100%) and 20 (57%) non-users completed their pain diary; median AUCs for pain were similar (65.0 vs. 59.5, p = 0.73). Thirteen (81%) patients subjectively correlated marijuana use with pain reduction, seven (44%) with anxiety reduction, and six (38%) with nausea/vomiting improvement. CONCLUSIONS: We found no significant difference in measures of medication abortion satisfaction and pain when comparing marijuana users to non-users. However, marijuana users often attributed symptom improvement during their medication abortion to marijuana use. IMPLICATIONS: Until randomized studies are available, clinicians can counsel patients that marijuana use may not necessarily affect satisfaction or pain with medication abortion. It remains unknown whether marijuana has potential benefits in a marijuana-naïve population undergoing medication abortion. Future studies should explore the role that marijuana and its derivatives may play for pain and side effect management during medication abortion among marijuana-naïve patients.

A pilot study on the effect of isotretinoin on serum etonogestrel concentrations in contraceptive implant users.

OBJECTIVE: To explore the pharmacokinetic interaction between isotretinoin, a cytochrome P-450 (CYP) inducer and potent teratogen, and the etonogestrel contraceptive implant. STUDY DESIGN: We enrolled healthy reproductive-age women initiating isotretinoin and using an etonogestrel implant. We compared serum etonogestrel concentrations at baseline and after four and nine weeks of isotretinoin co-administration using a validated assay. RESULTS: Among eight implant users, all serum etonogestrel concentrations remained >90 pg/mL during isotretinoin co-administration with no significant changes from baseline (p = 0.25, Friedman's test). CONCLUSION: In this exploratory study, we found that isotretinoin did not cause serum etonogestrel concentrations to fall below the threshold for ovulatory suppression (<90 pg/mL) among implant users. IMPLICATIONS: Reproductive-age women treated with isotretinoin require reliable contraception to prevent pregnancies impacted by teratogenic-effects. This small study demonstrates that contraceptive implant users maintained serum etonogestrel concentrations above the threshold for consistent ovulatory suppression during isotretinoin co-administration. The contraceptive implant remains an appropriate option for patients considering isotretinoin therapy.

Family planning training at Catholic and other religious hospitals: a national survey.

BACKGROUND: Catholic and other faith-based hospitals often restrict family planning service provision based on institutional doctrine. Approximately 11% of US accredited obstetrics and gynecology residency programs occur at such hospitals, creating a challenge to educational leaders who must ensure comprehensive family planning training. OBJECTIVE: To evaluate and summarize family planning training at obstetrics and gynecology residency programs that are affiliated with Catholic and other faith-based hospitals that restrict reproductive services. MATERIALS AND METHODS: Using an online database search and survey screening questions, we identified 30 of 278 accredited 2017-2018 programs in which at least 70% of resident time is spent in faith-based hospitals that restrict family planning services; Jewish programs were excluded. We queried program leaders between March 2017 and April 2018 about education and training using an online or paper survey, and asked them to report on training settings, provision of family planning services in such settings, and to rate aspects of training as "poor," "adequate," or "strong." We compared responses at Catholic versus other faith-based programs using Fisher exact tests, χ2 analyses, and median tests. RESULTS: Among 30 programs, 25 responded (83%); the majority of respondents were program directors (88%) and represented Catholic hospitals (76%). All reported adequate contraceptive training, with 47% of Catholic programs relying on off-site locations. The majority of Catholic sites (84%) relied on off-site sterilization training sites. Survey respondents from Catholic programs most commonly endorsed concerns for inadequate training in postpartum tubal ligations (53% of Catholic respondents versus 0% of other faith-based program respondents, P = .05). Approximately one-half (56%) offered abortion training as part of the curriculum ("routine"), 32% offered residents the opportunity to arrange training ("elective"), and 12% did not offer; the majority (84%) relied on off-site collaborations. Catholic sites were more likely than other religious programs to report poor abortion training (47% versus 0%, P = .04). Five Catholic programs (26% of Catholic programs) reported that their residents did not meet the graduate training requirement for completion of 20 dilation and curettage procedures. One-third reported a prior Residency Review Committee family planning citation(s), and many commented that these citations helped provide leverage for improved training. CONCLUSION: Although Catholic and other restrictive, faith-based obstetrics and gynecology residency training programs have developed strategies in response to institutional restrictions, many report ongoing deficiencies, and almost one-half reported they were noncompliant with abortion training requirements. Programs with deficient trainings may benefit from strategic approaches, including enhanced onsite education and collaborations with off-site facilities.

Prevention and Management of Severe Obstetric Anal Sphincter Injuries (OASIs): a National Survey of Nurse- Midwives.

INTRODUCTION AND HYPOTHESIS: There are no data on midwives' knowledge and management of obstetric anal sphincter injuries (OASIs) in the USA. We performed a cross-sectional national survey characterizing OASI practice by certified nurse midwives (CNMs), hypothesizing that few midwives personally repair OASIs and that there are gaps in CNM OASI training/education. METHODS: We emailed a REDCap internet-based survey to 6909 American College of Nurse Midwives members (ACNM). We analyzed responses from active clinicians performing at least one delivery per month, asking about OASI risks, prevention, repair, and management. We summarized descriptive data then evaluated OASI knowledge by patient and provider characteristics. RESULTS: We received 1070 (15.5%) completed surveys, and 832 (77.8%) met the inclusion/exclusion criteria. Participants were similar to ACNM membership. Respondents most frequently identified prior OASI (87%) and nutrition (71%) as antepartum OASI risk factors and, less frequently, nulliparity (36%) and race (22%). Identified intrapartum risks included forceps delivery (94%) and midline episiotomy (88%). When obstetric laceration is suspected, 13.6% of respondents perform a rectal examination routinely. Only 15% of participants personally perform OASI repair. Overall, participants matched 64% of evidence-based answers. OASI education/training courses were attended by 30% of respondents, and 44% knew of OASI protocols within their group/institution. Of all factors evaluated, the percent of evidence-based responses was only different for respondent education/CME and protocols. CONCLUSIONS: Quality initiatives regarding OASI prevention and management may improve care. Our data suggest OASI training for midwives may improve delivery care in the US. Further studies of other obstetric providers are needed.

Religious refusals to long-acting reversible contraceptives in Catholic settings: a call for evidence.

No-cost contraceptive provisions as in the Affordable Care Act have substantially reduced the financial burdens that patients previously faced with long-acting reversible contraception (LARC) access. Such efforts have contributed to improved LARC uptake and substantial declines in unintended pregnancy and abortion rates. However, governmental protections that allow religious restrictions to care to be implemented at institutional and systemic levels currently limit equitable access by healthcare consumers. A significant proportion of the US healthcare market is controlled by Catholic healthcare systems, which use moral teachings to inform guidelines to care. Many patients do not realize that their healthcare choices will be affected by attendance at a Catholic institution, in part because such facilities do little to inform patients of restrictions to common reproductive services including LARC. Limited data demonstrate that often hormonal intrauterine devices are provided through workarounds, but that implants and copper intrauterine devices are rarely available or approved in Catholic settings. The scarcity of data, particularly on patient outcomes, is in part explained by research barriers within Catholic settings. This Call for Action sets forth the notion that we should no longer remain complicit with allowances for institutional religious refusals of care unless we understand medical and ethical outcomes.