Acceptability of Postpartum Contraception Counseling at the Well Baby Visit.

Objectives The postpartum period is a high-risk time for unintended pregnancy, and additional opportunities to provide contraception are needed. Our objective was to evaluate the acceptability of providing postpartum contraceptive counseling at a pediatric well baby visit, and compare it to counseling at the routine postpartum visit. Methods Postpartum women (100 per group) were recruited for this cohort study at pediatric well baby visits and obstetric postpartum visits at an academic medical center. Well baby participants completed a baseline survey followed by contraceptive counseling by an obstetrician or midwife and a post-counseling survey. Postpartum participants were surveyed after their visit only. Results All well baby visit participants completed the intervention and were enrolled earlier in the postpartum period than postpartum visit participants (mean = 4.1 vs. 6.6 weeks, respectively, p < 0.01). Following counseling, 95% of well baby participants reported being very comfortable discussing contraception, compared to 83% before counseling (RR 1.14, 95% CI 1.06, 1.25) and a higher proportion reported being very likely to use a contraception prescription obtained at the well baby visit (79% after counseling vs. 65% before; RR 1.23, 95% CI 1.08, 1.39). Similar proportions of postpartum and well baby participants were very comfortable discussing contraception at their visits (91 vs. 95%, respectively). Conclusions for practice Contraceptive counseling paired with well baby visits is acceptable among postpartum women. Acceptability increased further after the counseling intervention at the well baby visit. Obstetricians and Pediatricians can partner to offer contraceptive counseling at the well baby visit to increase opportunities for contraception education at an earlier time postpartum.

Differential gene expression during placentation in pregnancies conceived with different fertility treatments compared with spontaneous pregnancies.

OBJECTIVE: To identify differences in the transcriptomic profiles during placentation from pregnancies conceived spontaneously vs. those with infertility using non-in vitro fertilization (IVF) fertility treatment (NIFT) or IVF. DESIGN: Cohort study. SETTING: Academic medical center. PATIENT(S): Women undergoing chorionic villus sampling at gestational age 11-13 weeks (n = 141), with pregnancies that were conceived spontaneously (n = 74), with NIFT (n = 33), or with IVF (n = 34), resulting in the delivery of viable offspring. INTERVENTION(S): Collection of chorionic villus samples from women who conceived spontaneously, with NIFT, or with IVF for gene expression analysis using RNA sequencing. MAIN OUTCOME MEASURE(S): Baseline maternal, paternal, and fetal demographics, maternal medical conditions, pregnancy complications, and outcomes. Differential gene expression of first-trimester placenta. RESULT(S): There were few differences in the transcriptome of first-trimester placenta from NIFT, IVF, and spontaneous pregnancies. There was one protein-coding differentially expressed gene (DEG) between the spontaneous and infertility groups, CACNA1I, one protein-coding DEG between the spontaneous and IVF groups, CACNA1I, and five protein-coding DEGs between the NIFT and IVF groups, SLC18A2, CCL21, FXYD2, PAEP, and DNER. CONCLUSION(S): This is the first and largest study looking at transcriptomic profiles of first-trimester placenta demonstrating similar transcriptomic profiles in pregnancies conceived using NIFT or IVF and spontaneous conceptions. Gene expression differences found to be highest in the NIFT group suggest that the underlying infertility, in addition to treatment-related factors, may contribute to the observed gene expression profiles.

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

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

Cervicovaginal colposcopic lesions associated with 5 nonoxynol-9 vaginal spermicide formulations.

OBJECTIVE: This study was undertaken to compare the colposcopic appearance of the cervicovaginal epithelium with spermicide use vs condom use in a low-risk population. STUDY DESIGN: This was an ancillary study of a trial comparing the efficacy of 5 nonoxynol-9 spermicides. A cohort of women who used condoms without spermicide served as a control group. Colposcopic examinations were performed during product use to identify genital lesions. RESULTS: One hundred fifty-one participants had 1 or more follow-up examinations. At baseline, study groups differed only by the prevalence of baseline lesions. New lesions were identified at 49% of follow-up visits. Controlling for the presence of a baseline lesion, compared with condom use none of the spermicides were associated with an increase in new lesions (overall odds ratio, 0.8; 95% CI, 0.4-1.6; P = .5); and lesions characterized by epithelial disruption were less frequent with spermicide use (overall odds ratio, 0.3; 95% CI, 0.1-0.6; P < .001). CONCLUSION: In a low-risk population, women who used nonoxynol-9 spermicides were less likely to have lesions with epithelial disruption, and equally likely to have any new lesion compared with condom use.

Adolescent and young adult women's knowledge of and attitudes toward the intrauterine device.

BACKGROUND: This study aimed to assess adolescent (aged 14-18 years) and young adult (aged 19-24 years) women's knowledge of and attitudes toward intrauterine devices (IUDs) before and after a brief educational intervention. STUDY DESIGN: We administered a 43-item survey to 144 women aged 14-24 years, with half in each age category. The survey assessed knowledge of and attitudes toward IUDs, and incorporated a 3-min educational intervention about IUDs. Predictors for knowledge of and attitudes toward the IUD were examined using logistic regression. RESULTS: Forty percent of participants had heard of the IUD. Having ever heard of the IUD was associated with age >18 years [adjusted odds ratio (OR)=5.7; 95% confidence interval (95% CI)=2.1-15.7], a higher level of maternal education (adjusted OR=4.5; 95% CI=1.5-13.3) and a history of voluntary sexual intercourse (adjusted OR=4.9; 95% CI=1.0-23.5). Of those who had heard of the IUD previously, 37.5% reported a positive attitude toward the IUD before the intervention. After the educational intervention, 53.5% of all participants reported a positive attitude toward the IUD, with both adolescent and young adult women having similarly positive attitudes (51.4% vs. 55.6%, p=.62). This positive attitude was associated only with a history of voluntary sexual intercourse (adjusted OR=5.2; 95% CI=1.3-21.1). The characteristics of the IUD that the participants strongly liked and disliked were rated similarly by the two age groups. However, more adolescent women considered the privacy of the IUD and the ability to use the copper IUD for 10 years as positive characteristics. CONCLUSION: Most young women were unaware of IUDs but were likely to think positively about IUDs after being educated about them. Demographic and reproductive health history did not predict attitude; thus, all young women should be offered education about IUDs.

Oral mifepristone and buccal misoprostol administered simultaneously for abortion: a pilot study.

BACKGROUND: Simultaneous oral mifepristone and vaginal misoprostol has a 24-h expulsion rate of approximately 90% when used for abortion through 63 days' gestation. This pilot study sought to determine if a simultaneous regimen using buccal misoprostol would be similarly effective and merit further investigation. STUDY DESIGN: One hundred twenty women were enrolled into three equal groups by gestational age: < or =49 days (Group 1), 50-56 days (Group 2) and 57-63 days (Group 3). After swallowing 200 mg of mifepristone, subjects received 800 mcg buccal misoprostol. Participants returned in 24+/-1 h for evaluation of expulsion by ultrasonography. Women with a persistent gestational sac received 800 mcg vaginal misoprostol. Further follow-up occurred at 1, 2 and 5 weeks by telephone or in person, as appropriate. Sample sizes for each group were estimated with the aim of establishing a 24-h expulsion rate of 90% (95% CI=76-95). RESULTS: The 24-h expulsion rates for Groups 1, 2 and 3 were 73% (95% CI=56-85), 69% (95% CI=52-83) and 73% (95% CI=56-85), respectively. Common side effects were nausea (62%), vomiting (33%) and diarrhea (48%), which did not differ by gestational age. Forty-three percent of subjects found the taste of buccal misoprostol objectionable; 30% found buccal retention uncomfortable or inconvenient, and 10% reported oral irritation, sensitivity, numbness or oral ulcers. CONCLUSIONS: Simultaneous oral mifepristone and buccal misoprostol had a lower-than-hypothesized expulsion rate at 24 h. Although overall success rates at 7 or 15 days could have been higher than those observed at 24 h, we believe that this regimen does not warrant further study.

Mifepristone and misoprostol for the treatment of early pregnancy failure: a pilot clinical trial.

BACKGROUND: In an attempt to improve efficacy for women who desire medical management of early pregnancy failure (EPF), we studied the efficacy and acceptability of mifepristone 200 mg, orally (po), followed 24 h later by misoprostol 800 microg, vaginally (pv), for the treatment of EPF. METHODS: We enrolled 30 women with EPF in this pilot clinical trial. All women used misoprostol 800 microg, pv, 24 h after ingesting 200 mg mifepristone. Follow-up evaluations with transvaginal ultrasonography occurred at 24 h and 1 week after treatment. Participants were offered a repeat dose of misoprostol if the pregnancy had not been expelled at the first follow-up. RESULTS: The expulsion rate with one dose of misoprostol was 90% (95% CI=79-100%). The overall success rate of the treatment was 93% (95% CI=84-100%). CONCLUSION: This regimen of mifepristone followed by vaginal misoprostol appears to be an efficacious and acceptable treatment for EPF and may have improved results over a single dose of misoprostol alone.

Training and attitudes about contraceptive management across primary care specialties: a survey of graduating residents.

PURPOSE: Little is known about how physicians' attitudes and knowledge of contraception could impact the unintended pregnancy rate in the United States. The objective of this study was to analyze survey data from physicians in primary care training programs in Pittsburgh, PA. METHODS: A cross-sectional survey was administered to primary care medical residents in Allegheny County, PA. Descriptive statistics were used to illustrate training, attitudes and knowledge regarding contraceptive management. A multivariable analysis was performed to elucidate associations between training, attitudes and behavior. RESULTS: Of 143 residents surveyed, 74 (52%) responded. The mean score on contraceptive knowledge assessment was 54%. Obstetrics/gynecology residents performed consistently better on the knowledge index (p<.01). Among nonobstetrics/gynecology residents, formal training in contraception, female gender, ability to insert an intrauterine device and not being a family practitioner were independently associated with improved knowledge (p<.05). CONCLUSIONS: Most of the responding graduating residents view contraception as an important component of primary care. However, young physicians have a contraceptive knowledge base that is inconsistent across primary care specialties. Improvement in this area might improve the unintended pregnancy rate in the United States.

Practices Regarding Rape-related Pregnancy in U.S. Abortion Care Settings.

OBJECTIVE: We aimed to explore current practices regarding screening for rape and response to disclosure of rape-related pregnancy in the abortion care setting. METHODS: We performed a cross-sectional, nonprobability survey of U.S. abortion providers. Individuals were recruited in person and via emailed invitations to professional organization member lists. Questions in this web-based survey pertained to providers' practice setting, how they identify rape-related pregnancy, the availability of support services, and their experiences with law enforcement. Providers were asked their perceptions of barriers to care for women who report rape-related pregnancy. RESULTS: Surveys were completed by 279 providers (21% response rate). Most respondents were female (93.1%), and the majority were physicians in a clinical role (69.4%). One-half (49.8%) reported their practice screens for pregnancy resulting from rape, although fewer (34.8%) reported that screening is the method through which most patients with this history are identified. Most (80.6%) refer women with rape-related pregnancy to support services such as rape crisis centers. Relatively few (19.7%) have a specific protocol for care of women who report rape-related pregnancy. Clinics that screen were 79% more likely to have a protocol for care than centers that do not screen. Although the majority (67.4%) reported barriers to identification of women with rape-related pregnancy, fewer (33.3%) reported barriers to connecting them to support services. CONCLUSION: Practices for identifying and providing care to women with rape-related pregnancy in the abortion care setting are variable. Further research should address barriers to care provision, as well as identifying protocols for care.

Same-day initiation of the transdermal hormonal delivery system (contraceptive patch) versus traditional initiation methods.

INTRODUCTION: Published comparisons of oral contraceptive pill (OCP) initiation methods demonstrate that OCP initiation at the office visit ("Quick Start") resulted in higher continuation rates into the second cycle. This trial was performed to investigate whether Quick Start with the contraceptive patch would provide similar results. MATERIALS AND METHODS: Sixty women were randomized to initiate use of the contraceptive patch using Quick Start (Group 1, n=30) or on the first day of their next menses (Group 2, n=30). Telephone contact at 6 weeks occurred to ensure that the second cycle had been initiated. A single follow-up visit was scheduled after completion of the third patch cycle. RESULTS: Continuation rates for Groups 1 and 2 were 97% and 93% (p=1.0), respectively, into the second cycle, and 93% and 90%, respectively, into the third cycle (p=1.0). Only approximately half of the subjects planned to continue using the patch after the study. CONCLUSION: Quick Start for the contraceptive patch did not improve continuation rates into the second or third cycle.

The true cost differential between mifepristone and misoprostol and misoprostol-alone regimens for medical abortion.

Our objective was to evaluate relative differences in direct and total (direct and indirect) costs for medical abortion regimens using mifepristone and misoprostol or misoprostol alone. We created formulas to evaluate relative differences in costs in the United States, Chennai (Madras), India, and a hypothetical developing country based on published protocols and efficacy data. Follow-up visits and suction aspiration procedures in the United States were evaluated over a range of costs. American indirect costs were estimated using earning data. Indirect costs in India and the hypothetical developing country were based on mifepristone cost differences between the United States and India. Although mifepristone costs US dollar 83.33 for every 200-mg tablet in the United States, the actual excess cost of using a mifepristone regimen, as compared with a misoprostol-alone regimen, is only US dollar 22 to US dollar 32. The actual cost of a mifepristone regimen is lower than that of a misoprostol-alone regimen in India. In a hypothetical developing country, a mifepristone regimen is likely to be less expensive than regimens using misoprostol alone. Because of the higher efficacy of medical abortion regimens using mifepristone and misoprostol and the need for fewer follow-up evaluations, such regimens are less expensive or only minimally more expensive than those using misoprostol alone.

A pilot study of mifepristone and misoprostol administered at the same time for abortion in women with gestation from 50 to 63 days.

INTRODUCTION: In the interest of decreasing the amount of time it takes to achieve a medical abortion, we performed a pilot study to evaluate the simultaneous administration of mifepristone and vaginal misoprostol for women with gestation from 50 to 63 days. MATERIALS AND METHODS: Forty women were enrolled with undesired pregnancies from 50 to 56 days' gestation (group 1) and 40 from 57 to 63 days' gestation (group 2). All women used misoprostol 800 mug vaginally immediately after having swallowed the 200 mg mifepristone tablet. Follow-up evaluations with transvaginal ultrasonography occurred at 24 h and 2 weeks after treatment. RESULTS: The 24-h expulsion rates were 88% (95% CI, 77-98) and 83% (95% CI, 7-94) in groups 1 and 2, respectively. The complete abortion rates at 2 weeks were 93% (95% CI, 84-100) and 90% (95% CI, 81-99), respectively. DISCUSSION: Simultaneous administration of oral mifepristone and vaginal misoprostol provides 24-h expulsion rates in women with gestation from 50 to 63 days, comparable to those reported in the medical literature for standard treatment regimens. Further study of this regimen in a large randomized trial is warranted.

A pilot study of mifepristone and misoprostol administered at the same time for abortion up to 49 days gestation.

HYPOTHESIS: Simultaneous administration of mifepristone and misoprostol for medical abortion in women up to 49 days gestation will result in complete abortion in 90% of women within 24 h of treatment. MATERIALS AND METHODS: Forty women with pregnancies up to 49 days gestation inserted 800 mug vaginal misoprostol in our office immediately after taking mifepristone 200 mg orally. Follow-up visits, which included vaginal ultrasonography, occurred 24+/-1 h and 2 weeks after treatment. If a gestational sac was still present at the first follow-up visit, the misoprostol dose was repeated. Suction abortion was performed for a viable gestation at the second follow-up visit, presence of a nonviable gestation within 5 weeks of treatment and when clinically indicated. RESULTS: Expulsion occurred in 36/40 (90%, 95% CI 80-99) and 39/40 (98%, 95% CI 93-100) women by the first and second follow-up visits, respectively. One woman who had initially expelled the gestational sac after a single dose of misoprostol later required a suction curettage for an incomplete abortion. CONCLUSION: Simultaneous administration of mifepristone and vaginal misoprostol is a promising regimen for medical abortion up to 49 days gestation.

"One Problem Became Another": Disclosure of Rape-Related Pregnancy in the Abortion Care Setting.

OBJECTIVE: We sought to explore the experiences of women who disclosed that their pregnancies resulted from rape in the abortion care setting, as well as the experiences of professionals involved in care of women with rape-related pregnancy. METHODS: In-depth interviews were conducted with 9 patients who had terminated rape-related pregnancies and 12 professionals working in abortion care or rape crisis advocacy (5 abortion providers, 4 rape crisis center advocates, 2 social workers, and 1 clinic administrator). Transcribed interviews were coded and analyzed for themes related to the experiences of disclosing rape and the consequences of disclosure in the abortion care setting. RESULTS: Patients and professionals involved in care of women with rape-related pregnancy described opportunities arising from disclosure, including interpersonal (explaining abortion decision making in the context of assault, belief, and caring by providers), as well as structural opportunities (funding assistance, legal options, and mental health options). Whereas most patients did not choose to pursue all three structural opportunities, both patients and professionals emphasized the importance of offering them. The most important consequence of disclosure for patients was being believed and feeling that providers cared about them. CONCLUSION: Rape-related pregnancy disclosure in the abortion care setting can lead to opportunities for interpersonal support and open options for funding, legal recourse, and mental health care. Those working in abortion care should create environments conducive to disclosure and opportunities for rape survivors to access these additional options if they desire.

Mifepristone and vaginal misoprostol on the same day for abortion from 50 to 63 days' gestation.

In a previous study of 40 women up to 49 days' gestation, our research center demonstrated that mifepristone 200 mg followed on the same day by misoprostol 800 microg vaginally produced abortion at rates similar to standard regimens which administer the two drugs 24 or 48 h apart. We performed this study to evaluate the same regimen in women with pregnancies at 50 to 63 days' gestation. Forty women from 50 to 56 days' gestation (Group 1) and 40 women from 57 to 63 days' gestation (Group 2) inserted misoprostol vaginally 6 to 8 h after taking mifepristone. Participants were instructed to return 24 +/- 1 h after using misoprostol for an evaluation that included transvaginal ultrasonography. Subjects who had not aborted received a second dose of misoprostol to administer 48 h after the mifepristone. All participants were to return 2 weeks later. Ultrasound examinations were performed in those who required a second dose of misoprostol to confirm the abortion was successful. At 24 h after receiving misoprostol, 37/40 (93%, 95% CI 80, 98%) and 36/40 (90%, 95% CI 76, 97%) women from Groups 1 and 2, respectively, had expelled the pregnancy. By follow-up 2 weeks after taking mifepristone, all 40 women in Group 1 (100%, 95% CI 91,100%) and 39/40 women in Group 2 (98%, 95% CI 87,100%) had complete abortions. One woman in the latter group who aborted within the first 24 h had an incomplete abortion treated by suction curettage. This pilot study suggests that mifepristone 200 mg, followed on the same day by misoprostol 800 microg vaginally, effects abortion in women 50 to 63 days' gestation at rates comparable to regimens using longer dosing intervals between medications. Though this regimen is promising, larger randomized trials comparing it to standard regimens are needed before widespread use.

Feasibility study of the use of a daily electronic mail reminder to improve oral contraceptive compliance.

Women who ingest their oral contraceptive pill (OCP) as part of a daily routine are more likely use their OCPs correctly. This trial examines the feasibility of an electronic-mail (e-mail) reminder system to improve OCP compliance. An e-mail reminder was sent to 50 new OCP users daily for 3 months. Subjects sent an e-mail reply to confirm receipt. OCP compliance was recorded on diaries. Four subjects were discontinued for not checking their e-mail. Active participants missed a median of 18% of the e-mail reminders (range: 0-65%). A follow-up visit was scheduled after completion of three OCP cycles. Of the 40 subjects returning completed diaries, 50% missed no active pills at all and 20% missed at least one in each cycle. Most found the daily e-mail somewhat (65%) or very helpful (19%) for OCP compliance. Of those continuing OCPs, 64% wanted to continue receiving e-mail reminders at the completion of the study. Because inconsistent OCP use is a significant cause of unplanned conception, the use of e-mail to improve OCP compliance has the potential to decrease unintended pregnancies.

Contraceptive need, counseling, and provision at the time of human papillomavirus vaccination on a catch-up schedule.

STUDY OBJECTIVE: Human papillomavirus vaccination may be given on a catch-up schedule to individuals between 13-26 years of age. Young women receiving human papillomavirus (HPV) vaccination during this time of adolescence and young adulthood may be at risk for pregnancy. We aimed to describe contraceptive need and contraceptive care for females at the time of HPV vaccination on a catch-up schedule. DESIGN: We performed a cross-sectional study of adolescents and young women who received HPV vaccination between June 2006 and May 2010. SETTING: University of Illinois Health Sciences Center. PARTICIPANTS: Females aged 13-26 years. MAIN OUTCOME MEASURES: Proportion of females receiving contraception counseling and provision at time of catch-up HPV vaccination. We used descriptive and chi-square statistics for analysis. RESULTS: 507 females, mean age 22 years, received HPV vaccination in the study period. Initiation of heterosexual activity was documented for 472 (94%). Of those who were currently sexually active, 316 (80%) were using contraception. The majority of all subjects (76%) were counseled on contraception at vaccination. Sexually active females were more likely to be counseled than those who had not initiated sexual activity (77% vs 54%, P = .002). Those vaccinated in primary care clinics were more likely to be counseled than in colposcopy clinics (87% vs 36%, P < .001). CONCLUSION: Young women presenting for HPV vaccination are often at risk of pregnancy. Onset of sexual activity and clinical site were associated with contraceptive care. HPV vaccination represents an opportunity to improve access to contraceptive care.

Factors associated with human papillomavirus vaccination completion on a catch-up schedule.

OBJECTIVE: "Catch-up vaccination" is vaccination outside of the recommended schedule and may occur between 13 and 26 years of age for human papillomavirus vaccines. We aimed to characterize those adolescents and young women who were most likely to complete the three-vaccine series on a catch-up schedule. METHODS: We performed a retrospective review of adolescents and young women aged 13-26 years who initiated human papillomavirus vaccination between January 2007 and April 2009 and followed them through April 2010 for vaccine completion (n=310). Completion was defined as receipt of three doses of the human papillomavirus vaccine. We used log binomial regression to investigate characteristics associated with vaccine completion. The main exposure was pregnancy occurring within 1 year of initiating the series. Other exposure variables included age, race, insurance, and clinical site. RESULTS: Fifty-six percent of participants completed the vaccine series with a mean follow-up of 2 years. After adjusting for age and site of vaccination, those who became pregnant (n=31) were significantly less likely than those who did not to complete the series (22.6% compared with 59.9%, respectively, adjusted relative risk 0.42, 95% confidence interval [CI] 0.21-0.81). Race or ethnicity was also independently associated with completion, with black patients having the lowest completion rate (48% compared with 72.1% among white patients, adjusted relative risk 0.71, 95% CI 0.54-0.91). CONCLUSION: Human papillomavirus vaccination completion is low among adolescents and females receiving vaccination on a catch-up schedule. Those who become pregnant may not resume the series after pregnancy. Vaccine initiation is an opportunity for contraceptive provision for adolescents and young women. LEVEL OF EVIDENCE: : II.

Long acting contraception provision by rural primary care physicians.

OBJECTIVES: Unplanned pregnancy is a public health problem in the United States, including in rural areas. Primary care physicians are the main providers of health care to women in rural areas and are uniquely positioned to help reduce unplanned pregnancy in rural women. This study documents provision of contraception by rural primary care physicians, focusing on the most effective, long acting methods, intrauterine devices (IUDs) and contraceptive implants. METHODS: We surveyed all primary care physicians practicing in rural areas of Illinois and Wisconsin. Bivariate analysis was performed using chi squared and Fisher's exact test, and multivariable analysis was performed with logistic regression to determine factors associated with provision. RESULTS: The response rate was 862 out of 2312 physicians (37%). Nine percent of respondents place implants and 35% place IUDs. Eighty-seven percent of physicians had not had training in implant placement, and 41% had not had training in IUD placement. In multivariable analysis, factors associated with placement of long acting contraception include provision of maternity care, and female gender of the physician. The most common reasons for not providing the methods were lack of training and perceived low demand from patients. CONCLUSIONS: Many rural primary care providers do not place long acting contraceptive devices due to lack of training. Female physicians and those providing maternity care are the most likely to place these devices. Increased training for primary care physicians both during and after residency would help increase access to these options for women in rural areas.

Sterilization of rural and urban women in the United States.

OBJECTIVE: To examine the prevalence of sterilization among women aged 20-34 years in rural and urban areas in the United States. METHODS: Data were obtained from the 2006-2010 National Survey of Family Growth, a cross-sectional survey conducted by the Centers for Disease Control and Prevention. The study population included the 4,685 female respondents who did not want to become pregnant at the time of the survey. Women who were not sexually active with men or were infertile for reasons other than contraception were excluded. We performed bivariate and stratified analysis and multivariable logistic regression modeling to determine the associations between place of residence and sterilization after considering other demographic characteristics. RESULTS: Rural women were at increased odds of undergoing sterilization compared with urban and suburban women (22.75% compared with 12.69%, respectively; crude odds ratio [OR] 2.03, 95% confidence interval [CI] 1.44-2.86; risk difference 0.10, 95% CI 0.05-0.16). Education level was found to be a significant effect modifier of the relationship between location of residence and sterilization. In adjusted analysis, controlling for age, parity, race and ethnicity, income, insurance status, history of unintended pregnancy, and relationship status, rural women without a high school degree were more likely to have undergone sterilization compared with urban and rural women with greater than a high school education (OR 8.34, 95% CI 4.45-15.61). CONCLUSIONS: Rural women with low education levels have a high prevalence of sterilization. Future studies need to address the reasons for this interaction between education and geography and its influence on contraceptive method choice. LEVEL OF EVIDENCE: II.