A Scoping Review of Patient-Centered Perinatal Contraceptive Counseling.

INTRODUCTION: Contraceptive counseling during the perinatal period is an important component of comprehensive perinatal care. We synthesized research about contraceptive counseling during the perinatal period, which has not previously been systematically compiled. METHODS: We developed search criteria to identify articles listed in PubMed, Embase, and Popline databases published between 1992 and July 2022 that address patients' preferences for, and experiences of, perinatal contraceptive counseling, as well as health outcomes associated with this counseling. Search results were independently reviewed by multiple reviewers to assess relevance for the present review. Methods were conducted in accordance with PRISMA guidelines. RESULTS: Thirty-four articles were included in the final full text review. Of the included articles, 10 included implementation and evaluation of a contraceptive counseling method or protocol, and 24 evaluated preferences for or experiences of existing contraceptive counseling in the perinatal period. Common themes included the acceptability of contraceptive counseling in the peripartum and postpartum periods, and a preference for contraceptive counseling at some point during the antenatal period and before the inpatient hospital experience, and direct provider-patient discussion instead of video or written material. Multiple studies suggest that timing, content, and modality should be individualized. In general, avoiding actual or perceived directiveness and providing multi-modal counseling that includes both written educational materials and patient-provider conversations was desired. DISCUSSION: The perinatal period constitutes a critical opportunity to provide contraceptive counseling that can support pregnant and postpartum people's management of their reproductive futures. The reviewed studies highlight the importance of patient-centered approach to providing this care, including flexibility of timing, content, and modality to accommodate individual preferences.

Implications of Overturning Roe v Wade on Abortion Training in US Family Medicine Residency Programs.

In June 2022, the US Supreme Court overturned Roe v Wade, opening the door to state-level abortion bans. By August 2023, 17 states banned abortion or instituted early gestational age bans. We performed an analysis to assess the proportion of accredited US family medicine residency programs and trainees in states with abortion restrictions. Twenty-nine percent of family medicine residency programs (n = 201) and residents (n = 3,930) are in states with bans or very restrictive policies. Family medicine residency programs must optimize training and exposure to abortion within their contexts, so graduates are able to care for patients seeking abortions or needing follow-up care.

Impact of an educational tool on young women's knowledge of cervical cancer screening recommendations.

PURPOSE: Current cervical cancer screening guidelines recommend 3-year screening intervals, in contrast to the previous recommendation of annual screening, to prevent over screening and overtreatment. We evaluated the impact of viewing a tablet-based educational tool prior to seeing a clinician on young women's knowledge and understanding of cervical cancer screening, HPV vaccination follow-up of abnormal pap smears, and comfort in communicating with their providers. METHODS: This cross-sectional study was part of a cluster-randomized study of fourteen primary care clinics from January 2015 to December 2016. We developed the cervical cancer education tool in English and Spanish using a community-based approach that included formative work and cognitive interviewing. Clinics were randomized to use the intervention (tablet-based patient education tool) or to participate as a control group. We administered surveys to a convenience sample of 229 English- or Spanish-speaking women aged 19 to 35 years in these clinics. We used descriptive analyses and logistic regression models with cluster-robust standard errors to compare differences among the two groups. RESULTS: Compared to women seen in control clinics, women seen in intervention clinics demonstrated greater knowledge regarding human papilloma virus (HPV (p = 0.004) and understanding (p < 0.001) of cervical cancer screening. Comfort in communicating with providers was not statistically different (p = 0.053). Women in the intervention group felt that the tool helped them understand that an abnormal Pap smear does not require immediate treatment (61.5%). CONCLUSION: Innovative online patient education that is offered prior to patients' interaction with their clinicians can improve their knowledge about cervical cancer prevention and treatment.

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

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

Examining socioeconomic status disparities in facility-based childbirth in Kenya: role of perceived need, accessibility, and quality of care.

BACKGROUND: Giving birth in health facilities with skilled birth attendants (SBAs) is one of the key efforts promoted to reduce preventable maternal deaths in sub-Saharan Africa. However, research has revealed large socioeconomic status (SES) disparities in facility-based childbirth. We seek to extend the literature on the factors underlying these SES disparities. Drawing on the Disparities in Skilled Birth Attendance (DiSBA) framework, we examined the contribution of three proximal factors-perceived need, accessibility, and quality of care-that influence the use of SBAs. METHODS: We used data from a survey conducted in Migori County, Kenya in 2016, among women aged 15-49 years who gave birth nine weeks before the survey (N = 1020). The primary outcome is facility-based childbirth. The primary predictors are wealth, measured in quintiles calculated from a wealth index based on principal component analysis of household assets, and highest education level attained. Proposed mediating variables include maternal perceptions of need, accessibility (physical and financial), and quality of care (antenatal services received and experience of care). Logistic regression with mediation analysis was used to investigate the mediating effects. RESULTS: Overall, 85% of women in the sample gave birth in a health facility. Women in the highest wealth quintile were more likely to give birth in a facility than women in the lowest quintile, controlling for demographic factors (adjusted odds ratio [aOR]: 2.97, 95% CI: 1.69-5.22). College-educated women were five times more likely than women with no formal education or primary education to give birth in a health facility (aOR: 4.96; 95% CI: 1.43-17.3). Women who gave birth in health facilities had higher perceived accessibility and quality of care than those who gave birth at home. The five mediators were estimated to account for between 15% and 48% of the differences in facility births between women in the lowest and higher wealth quintiles. CONCLUSION: Our results confirm SES disparities in facility-based childbirth, with the proximal factors accounting for some of these differences. These proximal factors - particularly perceived accessibility and quality of care - warrant attention due to their relationship with facility-birth overall, and their impact on inequities in this care.

Development and Pilot Testing of a Patient-Centered Web-Based Reproductive Decision Support Tool for Primary Care.

BACKGROUND: Patient-centered counseling to help women achieve their reproductive goals is an essential yet often absent component of primary care. OBJECTIVE: We developed and piloted MyPath, a novel web-based decision support tool integrating reproductive goals assessment, information about optimizing health before pregnancy, and contraceptive decision support, for use prior to primary care visits in the Veterans Administration (VA). DESIGN: We created MyPath using best practices for decision tool development, including a conceptual framework informed by theory and user-centered design with input from patients, providers, and scientific experts. We conducted a non-randomized pilot in two VA Women's Health primary care clinics. A control group (n = 28) was recruited prior to and intervention group (n = 30) recruited after introduction of MyPath into clinics. PARTICIPANTS: Women Veterans ages 18-44 with an upcoming visit scheduled with one of eight providers. INTERVENTIONS: After recruitment of controls, providers and staff received a brief introduction to MyPath. Patients scheduled to see providers in the intervention phase used MyPath on an iPad in the waiting room prior to their visit. MAIN MEASURES: Acceptability, feasibility, discussions about pregnancy and/or contraceptive needs, and contraceptive decision quality by a survey of participants and providers. KEY RESULTS: Nearly all participants who used MyPath reported they learned new information (97%) and would recommend it to other Veterans (93%). No providers reported that MyPath significantly increased workload. A greater proportion of intervention participants reported having discussions about reproductive needs in their visit compared to controls (93% vs 68%; p = 0.02). Intervention participants also experienced greater increases in pre-/post-visit knowledge and communication self-efficacy and a trend towards greater reduction in contraceptive decision conflict compared to controls. CONCLUSIONS: MyPath was highly acceptable to women, increased the proportion of primary care visits addressing reproductive needs, and improved decision quality without increasing providers' perceived workload. A larger randomized evaluation of effectiveness is warranted.

Patient-Led Decision-Making for HIV Preexposure Prophylaxis.

PURPOSE OF REVIEW: Shared decision-making is a process that involves bidirectional exchange of information between patients and providers to support patients in making individualized, evidence-based decisions about their healthcare. We review the evidence on patient-led decision-making, a form of shared decision-making that maximizes patient autonomy, as a framework for decisions about HIV preexposure prophylaxis (PrEP). We also assess the likelihood that patient-led decision-making occurs for PrEP and describe interventions to facilitate this process. RECENT FINDINGS: Patient-led decision-making is likely to be uncommon for PrEP, in part because healthcare providers lack knowledge and training about PrEP. Few evidence-based interventions exist to facilitate patient-led decision-making for PrEP. There is a need for rigorously developed interventions to increase knowledge of PrEP among patients and healthcare providers and support patient-led decision-making for PrEP, which will be increasingly important as the range of available PrEP modalities expands.

Beyond same-day long-acting reversible contraceptive access: a person-centered framework for advancing high-quality, equitable contraceptive care.

In the last decade-plus, there has been growing enthusiasm for long-acting reversible contraceptive methods as the solution to unintended pregnancy in the United States. Contraceptive access efforts have primarily focused on addressing provider and policy barriers to long-acting reversible contraception and have promoted long-acting reversible contraception as first-line methods through marketing and tiered-effectiveness counseling. A next generation of contraceptive access efforts has the opportunity to move beyond this siloed focus on long-acting reversible contraception toward a focus on equity and person-centeredness. Here we define a new framework for increasing equitable access to high-quality, person-centered contraceptive care that includes programmatic elements necessary to provide information and services to address the barriers to accessing quality care, organized into a four-part continuum. The continuum is contextualized within structural, systematic, and social factors that influence experience of contraceptive care. We aim to provide a practical framework for researchers, program implementers, and policy makers to develop and evaluate efforts to improve equitable access to and quality of contraceptive care. Initiatives can intentionally be cognizant of broader structural and social factors that will influence their success and the likelihood of negative unintended consequences for marginalized groups and thus deliberately work to design programs that meet all people's contraceptive needs and support reproductive autonomy.

Meeting the Needs of Postpartum Women With and Without a Recent Preterm Birth: Perceptions of Maternal Family Planning in Pediatrics.

OBJECTIVES: Women face distinct barriers to meeting their reproductive health needs postpartum, especially women who deliver preterm. Pediatric encounters present unique opportunities to address women's family planning, particularly within 18 months of a prior pregnancy, when pregnancy has an elevated risk of an adverse outcome, such as preterm birth. To ensure maternal family planning initiatives are designed in a patient-centered manner, we explored perspectives on addressing reproductive health in a pediatric setting among women with and without a recent preterm delivery. METHODS: We conducted semi-structured, qualitative interviews with 41 women (66% delivered preterm). Women who delivered at any gestational age were interviewed at a pediatric primary care clinic. We also interviewed women whose infants were either in a level II intensive care nursery or attending a high-risk infant follow-up clinic, all of whom had delivered preterm. Data were analyzed using team-based coding and theme analysis. RESULTS: While women's preferred timing and setting for addressing peripartum contraception varied, they largely considered pediatric settings to be an acceptable place to discuss family planning. A few women felt family planning fell outside of the pediatric scope or distracted from the child focus. Women discussed various barriers to accessing family planning care postpartum, including circumstances unique to women who delivered preterm. CONCLUSIONS FOR PRACTICE: Family planning interventions in pediatric settings were overall an acceptable approach to reducing barriers to care among our sample of women who predominantly delivered preterm. These exploratory findings justify further investigation to assess their generalizability and to develop maternal family planning interventions for pediatric settings.

Cluster randomized trial of a patient-centered contraceptive decision support tool, My Birth Control.

BACKGROUND: Research suggests the need for improvement in the patient-centeredness and comprehensiveness of contraceptive counseling. My Birth Control is a tablet-based decision support tool designed to improve women's experience of contraceptive counseling and to help them select contraceptive methods that are consistent with their values and preferences. OBJECTIVE: The objective of this study was to evaluate the effect of My Birth Control on contraceptive continuation, experience of contraceptive care, and decision quality. STUDY DESIGN: Using a cluster randomized design, randomized at the provider level, patient participants interested in starting or changing contraception interacted with My Birth Control before their family planning visit (intervention) or received usual care (control). A postvisit survey assessed experience of care method satisfaction, decision quality, and contraceptive knowledge. Surveys at 4 and 7 months assessed the primary outcome of contraceptive continuation, along with method use, satisfaction, and unintended pregnancy. Mixed-effects logistic regression models with multiple imputation for missing data were used to examine the effect of treatment assignment. RESULTS: Twenty-eight providers participated and 758 patients enrolled between December 5, 2014, and February 5, 2016. Participants were racially/ethnically diverse; less than a quarter self-identified as white. No effect was found on 7-month continuation (56.6% and 59.6% for intervention and control group respectively, odds ratio, 0.89; 95% confidence interval, 0.65-1.22). However, assignment to the intervention group increased reporting of the greatest Interpersonal Quality of Family Planning score (66.0% vs 57.4%, odds ratio, 1.45; 95% confidence interval, 1.03-2.05), the greatest scores on the informed decision and uncertainty subscales of the Decisional Conflict Scale (50.5% vs 43.2%, odds ratio, 1.34; 95% confidence interval, 1.0-1.80 and 41.6% vs 33.3%, odds ratio, 1.45; 95% confidence interval, 1.03-2.05), and greater knowledge. CONCLUSION: My Birth Control had no effect on contraceptive continuation. The intervention did enhance the experience of contraceptive counseling and informed decision making, as well as contraceptive knowledge., The intervention's effect on patient experience is important, particularly given the personal nature of contraceptive decision making and the social and historical context of family planning care.

Perioperative pregnancy interval, contraceptive counseling experiences, and contraceptive use in women undergoing bariatric surgery.

BACKGROUND: Reproductive-aged women represent about half of those undergoing bariatric surgery in the United States. Obstetric and bariatric professional societies recommend that women avoid pregnancy for 12-18 months postoperatively due to concern for increased pregnancy risks, and that providers should counsel women about these recommendations and their contraceptive options. However, knowledge about women's experience with perioperative counseling and postoperative contraceptive use is limited. OBJECTIVE: We sought to: (1) determine prevalence of perioperative contraceptive and pregnancy interval discussions among women who have recently undergone bariatric surgery; and (2) describe postoperative contraceptive use within the first year of surgery in this population. STUDY DESIGN: We performed a cross-sectional study of US women, aged 18-45 years and recruited through Facebook, who underwent bariatric surgery within the last 24 months. RESULTS: We enrolled 363 geographically diverse women. Three-quarters recalled perioperative pregnancy or contraceptive discussions, the majority with a bariatric provider. Half felt it was "very important" to discuss these issues perioperatively, and 41% of those who reported discussions wished they had had more. Of the 66% of women who reported using contraception in the first 12 months postoperatively, 27% used oral contraceptives and 26% used an intrauterine device. One third of contraceptive users who had undergone Roux-en-Y gastric bypass, a combined restrictive-malabsorptive procedure, were using oral contraceptives. Perioperative contraceptive or pregnancy discussions were independently associated with increased postoperative contraceptive use (odds ratios, 2.5; 95% confidence interval, 1.5-4.3, P < .001). CONCLUSION: A substantial proportion of women who had undergone bariatric surgery reported having had no perioperative pregnancy or contraception counseling, and many women who had felt the discussions were insufficient. Those who had had perioperative discussions were more likely to use contraception postoperatively. Reproductive-aged women should be routinely counseled perioperatively about pregnancy and contraception in the context of their reproductive desires, so they can make informed decisions about perioperative pregnancy prevention and contraceptive method use.

Women's preferences for contraceptive counseling in Mexico: Results from a focus group study.

BACKGROUND: Client-centered contraceptive counseling is critical to meeting demand for contraception and protecting human rights. However, despite various efforts to optimize counseling, little is known outside of the United States about what individuals themselves value in counseling. In the present study we investigate women's preferences for contraceptive counseling in Mexico to inform efforts to improve service quality. METHODS: We conducted applied qualitative research, using six focus group discussions with 43 women in two cities in Mexico with distinct sizes and sociocultural contexts (Mexico City and Tepeji del Río, Hidalgo) to assess contraceptive counseling preferences. We used a framework approach to thematically code and analyze the transcriptions from focus groups. RESULTS: Consistent with quality of care and human rights frameworks for family planning service delivery, participants expressed a desire for privacy, confidentiality, informed choice, and respectful treatment. They expanded on usual concepts of respectful care within family planning to include avoidance of sexual assault or harassment-in line with definitions of respectful care in maternal health. In contrast to counseling approaches with method effectiveness as the organizing principle, participants preferred counseling centered on personalized assessments of needs and preferences. Many, particularly older, less educated women, highly valued hearing provider opinions about what method they should use, based on those personalized assessments. Participants highlighted the necessity of clinical assessments or physical exams to inform provider recommendations for appropriate methods. This desire was largely due to beliefs that more exhaustive medical exams could help prevent negative contraceptive outcomes perceived to be common, in particular expulsion of intra-uterine devices (IUDs), by identifying methods compatible with a woman's body. Trust in provider, built in various ways, was seen as essential to women's contraceptive needs being met. CONCLUSIONS: Findings shed light on under-represented perspectives of clients related to counseling preferences. They highlight specific avenues for service delivery improvement in Mexico to ensure clients experience privacy, confidentiality, informed choice, respectful treatment, and personalized counseling-including around reasons for higher IUD expulsion rates postpartum-during contraceptive visits. Findings suggest interventions to improve provider counseling should prioritize a focus on relationship-building to foster trust, and needs assessment skills to facilitate personalization of decision-making support without imposition of a provider's personal opinions. Trust is particularly important to address in family planning given historical abuses against women's autonomy that may still influence perspectives on contraceptive programs. Findings can also be used to improve quantitative client experience measures.

Addressing potential pitfalls of reproductive life planning with patient-centered counseling.

Engaging women in discussions about reproductive goals in health care settings is increasingly recognized as an important public health strategy to reduce unintended pregnancy and improve pregnancy outcomes. "Reproductive life planning" has gained visibility as a framework for these discussions, endorsed by public health and professional organizations and integrated into practice guidelines. However, women's health advocates and researchers have voiced the concern that aspects of the reproductive life planning framework may have the unintended consequence of alienating rather than empowering some women. This concern is based on evidence indicating that women may not hold clear intentions regarding pregnancy timing and may have complex feelings about achieving or avoiding pregnancy, which in turn may make defining a reproductive life plan challenging or less meaningful. We examine potential pitfalls of reproductive life planning counseling and, based on available evidence, offer suggestions for a patient-centered approach to counseling, including building open and trusting relationships with patients, asking open-ended questions, and prioritizing information delivery based on patient preferences. Research is needed to ensure that efforts to engage women in conversations about their reproductive goals are effective in both achieving public health objectives and empowering individual women to achieve the reproductive lives they desire.

Immediate versus delayed postpartum use of levonorgestrel contraceptive implants: a randomized controlled trial in Uganda.

BACKGROUND: Use of long-acting, highly effective contraception has the potential to improve women's ability to avoid short interpregnancy intervals, which are associated with an increased risk of maternal morbidity and mortality, and preterm delivery. In Uganda, contraceptive implants are not routinely available during the immediate postpartum period. OBJECTIVE: The purpose of this study was to compare the proportion of women using levonorgestrel contraceptive implants at 6 months after delivery in women randomized to immediate or delayed insertion. STUDY DESIGN: This was a randomized controlled trial among women in Kampala, Uganda. Women who desired contraceptive implants were randomly assigned to insertion of a 2-rod contraceptive implant system containing 75 mg of levonorgestrel immediately following delivery (within 5 days of delivery and before discharge from the hospital) or delayed insertion (6 weeks postpartum). The primary outcome was implant utilization at 6 months postpartum. RESULTS: From June to October 2015, 205 women were randomized, 103 to the immediate group and 102 to the delayed group. Ninety-three percent completed the 6 month follow-up visit. At 6 months, implant use was higher in the immediate group compared with the delayed group (97% vs 68%; P < .001), as was the use of any highly effective contraceptive (98% vs 81%; P = .001). Women in the immediate group were more satisfied with the timing of implant placement. If given the choice, 81% of women in the immediate group and 63% of women in the delayed group would choose the same timing of placement again (P = .01). There were no serious adverse events in either group. CONCLUSION: Offering women the option of initiating contraceptive implants in the immediate postpartum period has the potential to increase contraceptive utilization, decrease unwanted pregnancies, prevent short interpregnancy intervals, and help women achieve their reproductive goals.

Multivariable regression analysis of list experiment data on abortion: results from a large, randomly-selected population based study in Liberia.

BACKGROUND: The list experiment is a promising measurement tool for eliciting truthful responses to stigmatized or sensitive health behaviors. However, investigators may be hesitant to adopt the method due to previously untestable assumptions and the perceived inability to conduct multivariable analysis. With a recently developed statistical test that can detect the presence of a design effect - the absence of which is a central assumption of the list experiment method - we sought to test the validity of a list experiment conducted on self-reported abortion in Liberia. We also aim to introduce recently developed multivariable regression estimators for the analysis of list experiment data, to explore relationships between respondent characteristics and having had an abortion - an important component of understanding the experiences of women who have abortions. METHODS: To test the null hypothesis of no design effect in the Liberian list experiment data, we calculated the percentage of each respondent "type," characterized by response to the control items, and compared these percentages across treatment and control groups with a Bonferroni-adjusted alpha criterion. We then implemented two least squares and two maximum likelihood models (four total), each representing different bias-variance trade-offs, to estimate the association between respondent characteristics and abortion. RESULTS: We find no clear evidence of a design effect in list experiment data from Liberia (p = 0.18), affirming the first key assumption of the method. Multivariable analyses suggest a negative association between education and history of abortion. The retrospective nature of measuring lifetime experience of abortion, however, complicates interpretation of results, as the timing and safety of a respondent's abortion may have influenced her ability to pursue an education. CONCLUSION: Our work demonstrates that multivariable analyses, as well as statistical testing of a key design assumption, are possible with list experiment data, although with important limitations when considering lifetime measures. We outline how to implement this methodology with list experiment data in future research.

Confronting the Medical Community's Complicity in Marginalizing Abortion Care.

This Viewpoint discusses the exclusion of abortion care from many established medical sources (such as hospitals) and from coverage by many major payers and how the health care system should legitimize and ensure clinician training in safe abortion care.

Association of the quality of interpersonal care during family planning counseling with contraceptive use.

BACKGROUND: Health communication and interpersonal skills are increasingly emphasized in the measurement of health care quality, yet there is limited research on the association of interpersonal care with health outcomes. As approximately 50% of pregnancies in the United States are unintended, whether interpersonal communication influences contraceptive use is of public health importance. OBJECTIVE: The aim of this study was to determine whether the quality of interpersonal care during contraceptive counseling is associated with contraceptive use over time. STUDY DESIGN: The Patient-Provider Communication about Contraception study is a prospective cohort study of 348 English-speaking women seen for contraceptive care, conducted between 2009 and 2012 in the San Francisco Bay Area. Quality of communication was assessed using a patient-reported interpersonal quality in family planning care measure based on the dimensions of patient-centered care. In addition, the clinical visit was audio recorded and its content coded according to the validated Four Habits Coding Scheme to assess interpersonal communication behaviors of clinicians. The outcome measures were 6-month continuation of the selected contraceptive method and use of a highly or moderately effective method at 6 months. Results were analyzed using mixed effect logistic regression models controlling for patient demographics, the clinic and the provider at which the visit occurred, and the method selected. RESULTS: Patient participants had a mean age of 26.8 years (SD 6.9 years); 46% were white, 26% Latina, and 28% black. Almost two-thirds of participants had an income of <200% of the Federal Poverty Level. Most of the women (73%) were making visits to a provider whom they had not seen before. Of the patient participants, 41% were still using their chosen contraceptive method at 6-month follow-up. Patients who reported high interpersonal quality of family planning care were more likely to maintain use of their chosen contraceptive method (adjusted odds ratio [aOR], 1.8; 95% CI, 1.1-3.0) and to be using a highly or moderately effective method at 6 months (aOR, 2.0; 95% CI, 1.2-3.5). In addition, 2 of the Four Habits were associated with contraceptive continuation; "invests in the beginning" (aOR, 2.3; 95% CI, 1.2-4.3) and "elicits the patient's perspective" (aOR, 1.8; 95% CI, 1.0-3.2). CONCLUSION: Our study provides evidence that the quality of interpersonal care, measured using both patient report and observation of provider behaviors, influences contraceptive use. These results provide support for ongoing attention to interpersonal communication as an important aspect of health care quality. The associations of establishing rapport and eliciting the patient perspective with contraceptive continuation are suggestive of areas of focus for provider communication skills training for contraceptive care.

Racial/ethnic disparities in contraceptive use: variation by age and women's reproductive experiences.

OBJECTIVE: Disparities in unintended pregnancy in the United States are related, in part, to black and Hispanic women being overall less likely to use effective contraceptive methods. However, the fact that these same groups are more likely to use female sterilization, a highly effective method, suggests there may be variability in disparities in contraceptive use across a woman's life course. We sought to assess the relationship between race/ethnicity and contraceptive use in a nationally representative sample and to approximate a life course perspective by examining effect modification on these disparities by women's age, parity, and history of unintended pregnancy. STUDY DESIGN: We conducted an analysis of the 2006 through 2010 National Survey of Family Growth to determine the association between race/ethnicity and: (1) use of any method; (2) use of a highly or moderately effective method among women using contraception; and (3) use of a highly effective method among women using contraception. We then performed analyses to assess interactions between race/ethnicity and age, parity, and history of unintended pregnancy. RESULTS: Our sample included 7214 females aged 15-44 years. Compared to whites, blacks were less likely to use any contraceptive method (adjusted odds ratio, 0.65); and blacks and Hispanics were less likely to use a highly or moderately effective method (adjusted odds ratio, 0.49 and 0.57, respectively). Interaction analyses revealed that racial/ethnic disparities in contraceptive use varied by women's age, with younger women having more prominent disparities. CONCLUSION: Interventions designed to address disparities in unintended pregnancy should focus on improving contraceptive use among younger women.