Impact of Medicaid expansion in Oregon on access to prenatal care.

Medicaid expansion under the Patient Protection and Affordable Care Act (ACA) has the potential to improve reproductive health by allowing low-income women access to healthcare before and early in pregnancy. The aim of this study was to examine the effects of Oregon's Medicaid expansion on timely and adequate prenatal care. We included live births in Oregon from 2012 to 2015 and used individually-linked birth certificate and Medicaid eligibility data. Outcomes were receipt of first trimester prenatal care and receipt of adequate prenatal care. We also assessed Medicaid enrollment one month prior to pregnancy. We estimated the overall effect of Medicaid expansion on prenatal care utilization using probit regression models. Additionally, we assessed the impact of Medicaid expansion on prenatal care utilization via pre-pregnancy Medicaid enrollment using bivariate probit models. Overall, receipt of first trimester prenatal care increased post-expansion by 1.5 percentage points (p < 0.01) after expansion. Receipt of adequate prenatal care also increased significantly post-expansion with an incremental increase of 2.8 percentage points (p < 0.001). Pre-pregnancy Medicaid enrollment increased following Medicaid expansion (ß = 0.55, p < 0.001) and was associated with both timely (ß = 0.48, p < 0.001) and adequate receipt of prenatal care (ß = 0.14, p < 0.001). Using two years of post-ACA data we found that Medicaid expansion had significant positive associations with Medicaid enrollment prior to pregnancy, which subsequently increased receipt of timely and adequate prenatal care. Our study provides evidence that expanding Medicaid has positive effects on women's use of healthcare.

Sexual activity and weekly contraceptive use among young adult women in Michigan.

Past studies on the influence of sexual activity on contraceptive behaviours are inconclusive, relying heavily on cross-sectional data. We used a population-based longitudinal sample of young women in Michigan to evaluate weekly associations between sexual activity and contraceptive use at three levels of measurement: comparing between women, among individual women's partnerships, and from week to week within partnerships. We used multinomial logistic regression accounting for correlations within partnerships and women. Relative to use of least effective methods, weekly sexual activity was significantly associated with increased use of condoms, pills, and highly effective methods. For pills and highly effective methods, partnership-, woman-, and week-level effects were similar. For condoms, there was no significant woman-level effect. Evidence of immediate effects of sexual activity on contraceptive use highlights the importance of longitudinal data. These dynamics may be diluted or missed altogether when relying on cross-sectional data approaches that compare groups of individuals.

Perceived partner fertility desires and influence on contraceptive use.

BACKGROUND: Perceived discordance of fertility desires may be more common among couples with certain sociodemographic characteristics and may lead to lower contraceptive use. METHODS: Using nationally representative data from adults ages 15-49 in France in 2010, we analysed associations between sociodemographic characteristics, perceived discordance of fertility desires and contraceptive use with design-based logistic regression. RESULTS: Only 8% of participants perceived discordant fertility desires while 92% perceived concordance with partner fertility desire. Discordance varied by age and relationship duration and by the presence of children from previous relationships. Perceived discordance was not associated with use of a hormonal or highly effective method. Beyond own intentions, perception of a partner's fertility desires was associated with using a highly effective method among participants using any method. CONCLUSIONS: Engaging men and couples in family planning programmes may be important for achieving both partners' desired fertility goals.

National Needs of Family Planning Among US Men Aged 15 to 44 Years.

OBJECTIVES: To estimate national need for family planning services among men in the United States according to background characteristics, access to care, receipt of services, and contraception use. METHODS: We used weighted data from the 2006-2010 National Survey of Family Growth to estimate the percentage of men aged 15 to 44 years (n = 10 395) in need of family planning, based on sexual behavior, fecundity, and not trying to get pregnant with his partner. RESULTS: Overall, 60% of men were in need of family planning, defined as those who ever had vaginal sex, were fecund, and had fecund partner(s) who were not trying to get pregnant with partner or partner(s) were not currently pregnant. The greatest need was among young and unmarried men. Most men in need of family planning had access to care, but few reported receiving family planning services (< 19%), consistently using condoms (26%), or having partners consistently using contraception (41%). CONCLUSIONS: The need for engaging men aged 15 to 44 years in family planning education and care is substantial and largely unmet despite national public health priorities to include men in reducing unintended pregnancies.

Peer and community influences on the acceptance of premarital sex among Vietnamese adolescents.

AIM: Adolescents in Vietnam have a low level of sexual activity, but this may increase with urbanisation and economic development. The aim of this analysis is to understand trends in correlates of permissive attitudes towards premarital sex among Vietnamese adolescents using an ecological framework. METHODS: Data from the Survey Assessment of Vietnamese Youth from 2003 (n = 7584) and 2009 (n = 10,044) were analysed using multivariable logistic regressions to examine associations between permissive attitudes towards premarital sex and demographic and contextual factors among adolescents aged 14 to 25. RESULTS: Correlates of having permissive attitudes towards premarital sex in both 2003 and 2009 included being male, older age, living in an urban area, living in the North, having ever used the Internet and perceiving that people in the community were having premarital sex. Variables that were significant in 2009 but not in 2003 included socio-economic status and belonging to an ethnic minority. Statistically significant changes in associations between 2003 and 2009 were observed for age, socio-economic status and belonging to an ethnic minority. CONCLUSIONS: The association of permissive attitudes with community norms and certain socio-demographic variables in conjunction with overarching economic development and urbanisation suggests that premarital sex will likely become increasingly common among Vietnamese adolescents. These trends should be further assessed as adolescent sexual activity becomes more common and adolescent friendly health services should be developed to provide appropriate and acceptable sexual and reproductive health care to young people.

Postabortion Medicaid Enrollment and the Affordable Care Act Medicaid Expansion in Oregon.

Background: The Affordable Care Act Medicaid expansion had the potential to increase continuity of insurance coverage and remove barriers to accessing health services following an abortion in states where Medicaid pays for abortion. We examined the association of Medicaid expansion with postabortion Medicaid enrollment and described postabortion preventive reproductive services among Medicaid-enrolled women in Oregon. Methods: We used Medicaid claims and enrollment data to identify abortions to women ages 20-44 in 2009-2017 (N = 30,786), classified into a treatment group-those likely to be affected by Medicaid expansion-and a comparison group. Outcomes included Medicaid enrollment (number of months enrolled and any lapse in enrollment) in the 6 and 12 months postabortion. Difference-in-differences analyses were used to compare outcomes preexpansion (2009-2012) and postexpansion (2014-2017) for treatment and comparison groups. Linear regression models were adjusted for age, race/ethnicity, rurality, and month. We described receipt of preventive reproductive services in 0-2 months and in 3-12 months postabortion. Results: Medicaid expansion was associated with enrollment increases of 2.0 and 4.7 months and with declines in any enrollment lapse of 54 and 48 percentage-points over 6 and 12 months postabortion, respectively (p < 0.001). Many who remained enrolled through postabortion received preventive care including contraceptive services (41%) and screening for sexually transmitted infections (23%). Conclusions: Medicaid expansion may increase continuity of insurance coverage for those receiving abortions, and in turn promote access to preventive services that can improve subsequent reproductive health outcomes.

Association of Medicaid Expansion With Access to Abortion Services for Women With Low Incomes in Oregon.

BACKGROUND: The Affordable Care Act allowed states to expand Medicaid eligibility for women with low incomes before pregnancy. Women who experience an unintended pregnancy may encounter fewer delays in accessing abortion services if they are already enrolled in Medicaid. In states where the Medicaid program includes coverage for abortion services, Medicaid expansion may increase timely access to abortion services. Oregon has expanded Medicaid and is 1 of 16 states in which the Medicaid program covers abortion services. We explored how Medicaid expansion in Oregon was associated with Medicaid-financed abortion rates and receipt of medication abortion relative to surgical abortion. METHODS: Using Medicaid claims and eligibility data we identified women ages 19 to 43 (n = 30,367) who had abortions before the expansion period (2008-2013) and after the expansion period (2014-2016). We used American Community Survey data to estimate the annual number of Oregon women aged 19 to 43 with incomes below 185% of the federal poverty level who would be eligible for a Medicaid-financed abortion. We conducted interrupted time series analyses using negative binomial and logistic regression models. RESULTS: Incidence of Medicaid-financed abortion increased from 13.4 in 1,000 women in 2008 to 16.3 in 2016. Medication abortion receipt increased from 11.5% of abortions in 2008 to 31.7% in 2016. For both outcomes, we identified an increasing time trend after Medicaid expansion, followed by a subsequent leveling off of the trend. By the end of 2016, incidence of Medicaid-financed abortion was 4.5 abortions per 1,000 women-years (95% confidence interval, 3.3-5.7) higher than it would have been without expansion and medication abortions comprised a 7.4 percentage point (95% confidence interval, 4.4-10.4) greater share of all abortions. CONCLUSIONS: Medicaid expansion was associated with increased receipt of Medicaid-financed abortions and may have reduced out-of-pocket payment among women with low incomes. Increased receipt of medication abortion may indicate that expansion enhanced earlier access to services, possibly as a result of increased prepregnancy Medicaid enrollment, and this earlier access may increase reproductive autonomy and safety.

Contraceptive Services After Medicaid Expansion in a State with a Medicaid Family Planning Waiver Program.

Background: Medicaid family planning programs provide coverage for contraceptive services to low-income women who otherwise do not meet eligibility criteria for Medicaid. In some states that expanded Medicaid eligibility following the Affordable Care Act (ACA), women who were previously eligible only for family planning services became eligible for full-scope Medicaid. The objective of this study was to provide context for the impact of the ACA Medicaid expansion on contraceptive service provision to women in Oregon who were newly enrolled in Medicaid following the expansion. Materials and Methods: We used Medicaid eligibility data to identify women ages 15-44 years who were newly enrolled in Oregon's Medicaid program following the ACA expansion (n = 305,042). Using Medicaid claims data, we described contraceptive services and other preventive reproductive care received in 2014-2017. Results: Overall, 20% of women newly enrolled in Medicaid received contraceptive counseling and 31% received at least one method. The most frequently received methods were the pill (38% of women who received any method), intrauterine device (28%), implant (15%), and injectable (12%). Community health centers played a significant role in contraceptive service provision, particularly for the implant and injectable. Nine of 10 women (89%) who received contraceptive services also received other preventive reproductive services. Conclusions: This study provides insight regarding receipt of contraceptive services and preventive reproductive care following Medicaid expansion in a state with a Medicaid family planning program. These findings underscore the importance of Medicaid expansion for reproductive health even in states with preexisting Medicaid family planning.

Pharmacist prescription and access to hormonal contraception for Medicaid-insured women in Oregon.

OBJECTIVE: To assess the impact of Oregon's policy that allows pharmacist prescription of the pill and patch on contraceptive receipt for Medicaid-insured women. STUDY DESIGN: We conducted a difference-in-differences analysis using Oregon Medicaid claims data to compare changes in receipt of all contraceptive services and receipt of the pill or patch for Medicaid-enrolled women (n = 436,258) before and after policy implementation in areas with and without participating pharmacists. We then described filled prescriptions for the contraceptive pill and patch by type of prescribing provider before and after implementation of the policy. We also compared past contraceptive use for women receiving prescriptions from pharmacists and non-pharmacists. RESULTS: We found no significant policy effects on receipt of all contraceptive services or on receipt of the pill or patch. More than 98% of prescriptions filled for the pill and patch in the first two years of policy implementation were prescribed by a non-pharmacist provider. Women receiving contraceptive pill and patch prescriptions from pharmacists and non-pharmacists were equally likely to be continuing contraceptive users. CONCLUSION: We identified no increase in receipt of contraceptive services among Medicaid-insured women in the two years following the implementation of a pharmacy access policy. Additional research is needed to investigate other possible benefits of the policy, such as satisfaction, convenience, cost and equity. IMPLICATIONS: We identified no effect of allowing pharmacist prescription of the contraceptive pill and patch on increasing utilization of contraceptive services for Medicaid-insured women in Oregon. Impacts on access to contraceptive services and unintended pregnancy may emerge in subsequent years as availability of and demand for pharmacist-prescribed hormonal contraception increases.

Development and validation of a claims-based measure of abortion services.

RATIONALE: Data on abortion services are critical for monitoring trends in access and utilization, evaluating policies, and examining a wide range of research questions. Accurate and timely data, however, can be difficult to obtain for abortion services. Oregon is one of several states that use state funds to finance abortion services in their Medicaid programmes. Oregon's Medicaid programme contracts with managed care plans that receive global budgets to provide care. Abortion services, however, must be billed directly to the state through fee-for-service (FFS) billing to ensure that federal funds are not used. In this study, we identify possible abortions using Medicaid insurance claims data from Oregon and categorize identified abortions as high, medium, or low confidence according to convergent validity analysis of FFS billing. METHODS: We used individually linked Medicaid eligibility and claims data from women ages 15 to 44 enrolled in Oregon's Medicaid programme from 2008 to 2013. Abortion-related Medicaid claims were identified and categorized based on diagnosis, procedure, and drug codes. These categories were assessed for convergent validity by examining FFS billing for possible abortions to women enrolled in managed care plans. RESULTS: In total, 23 763 possible abortions obtained by 18 518 women were classified with high (n = 21 450), medium (n = 562), and low (n = 1751) confidence. Among managed care abortions, more than 99% of high confidence abortions were billed on an FFS basis compared with 72% of medium confidence and <1% of low confidence abortions. The majority of high confidence abortions were to urban-residing (89%) white (73%) women. CONCLUSIONS: Research on abortion services using insurance claims has important implications for women's health care and public health policy. A high-quality claims-based measure can facilitate monitoring the provision of abortion services within health systems and evaluation of initiatives to increase equitable abortion access.

Sexual Activity and Weekly Contraceptive Discontinuation and Selection Among Young Adult Women in Michigan.

Understanding young women's contraceptive and pregnancy prevention behaviors is important for helping women and their partners control if and when they have children. Prior research on associations between patterns of sexual activity and contraceptive behaviors is limited. We assessed the influence of recent sexual activity on discontinuation and selection of specific contraceptive methods. We used weekly data from the Relationship Dynamics and Social Life (RDSL) study, a longitudinal 2.5-year population-based project that sampled woman ages 18 and 19 (N = 1,003) in one Michigan county. We estimated logistic and multinomial regression models that accounted for clustering of weekly observations within partnerships and women. Weekly discontinuation of longer-acting methods declined with increasing sexual activity in the past month, as did discontinuation of shorter-acting hormonal methods. Sexual activity was associated with decreased selection of condoms relative to other methods. Future research into life events that lead to changes in the frequency of sexual activity may provide insight into times when women are at risk of contraceptive discontinuation. These findings underscore the importance of anticipatory guidance in contraceptive counseling so that when women change their contraceptive behavior they are equipped in advance with resources to make safe transitions between methods.

Sexual and Reproductive Health Care Receipt Among Young Males Aged 15-24.

PURPOSE: This study aimed to describe young men's sexual and reproductive health care (SRHC) receipt by sexual behavior and factors associated with greater SRHC receipt. METHODS: There were 427 male patients aged 15-24 who were recruited from 3 primary care and 2 sexually transmitted disease (STD) clinics in 1 urban city. Immediately after the visit, the survey assessed receipt of 18 recommended SRHC services across four domains: screening history (sexual health, STD/HIV test, family planning); laboratories (STDs/HIV); condom products (condoms/lubrication); and counseling (STD/HIV risk reduction, family planning, condoms); in addition, demographic, sexual behavior, and visit characteristics were examined. Multivariable Poisson regressions examined factors associated with each SRHC subdomain adjusting for participant clustering within clinics. RESULTS: Of the participants, 90% were non-Hispanic black, 61% were aged 20-24, 90% were sexually active, 71% had female partners (FPs), and 20% had male or male and female partners (M/MFPs). Among sexually active males, 1 in 10 received all services. Half or more were asked about sexual health and STD/HIV tests, tested for STDs/HIV, and were counseled on STD/HIV risk reduction and correct condom use. Fewer were asked about family planning (23%), were provided condom products (32%), and were counseled about family planning (35%). Overall and for each subdomain, never sexually active males reported fewer services than sexually active males. Factors consistently associated with greater SRHC receipt across subdomains included having M/MFPs versus FPs, routine versus non-STD-acute visit, time alone with provider without parent, and seen at STD versus primary care clinic. Males having FPs versus M/MFPs reported greater family planning counseling. CONCLUSIONS: Findings have implications for improving young men's SRHC delivery beyond the narrow scope of STD/HIV care.

Do Nonclinical Community-Based Youth-Serving Professionals Talk With Young Men About Sexual and Reproductive Health and Intend to Refer Them for Care?

Young men (ages 15-24) may benefit from community-based connections to care since many have sexual and reproductive health (SRH) needs and low care use. This study describes nonclinical community-based youth-serving professionals' (YSPs) SRH knowledge, confidence, past behaviors, and future intentions to talk with young men about SRH and refer them to care, and examines factors associated with care referral intentions. YSPs ( n = 158) from 22 settings in one mid-Atlantic city answered questions about the study's goal, their demographics and work environment from August 2014 to December 2015. Poisson regression assessed factors associated with YSPs' care referral intentions. On average, YSPs answered 58% of knowledge questions correctly, knew 5 of 8 SRH care dimensions of where to refer young men, and perceived being somewhat/very confident talking with young men about SRH (63%) and referring them to care (77%). During the past month, the majority (63%) talked with young men about SRH but only one-third made care referrals; the majority (66%) were somewhat/very likely to refer them to care in the next 3 months. Adjusted models indicated YSPs were more likely to refer young men if they had a very supportive work environment to talk about SRH (adjusted RR = 1.51, 95% CI [1.15, 1.98]), greater confidence in SRH care referral (1.28 [1.00, 1.62]), and greater SRH care referrals in the past month (1.16 [1.02, 1.33]). Nonclinical community-based YSPs have poor-to-moderate knowledge about young men's SRH care, and less than one-third reported referrals in the past month. Findings have implications for educating YSPs about young men's SRH care.

Long-Acting Reversible Contraception Counseling and Use for Older Adolescents and Nulliparous Women.

PURPOSE: The majority of pregnancies during adolescence are unintended, and few adolescents use long-acting reversible contraception (LARC) due in part to health care providers' misconceptions about nulliparous women's eligibility for the intrauterine device. We examined differences in LARC counseling, selection, and initiation by age and parity in a study with a provider's LARC training intervention. METHODS: Sexually active women aged 18-25 years receiving contraceptive counseling (n = 1,500) were enrolled at 20 interventions and 20 control clinics and followed for 12 months. We assessed LARC counseling and selection, by age and parity, with generalized estimated equations with robust standard errors. We assessed LARC use over 1 year with Cox proportional hazards models with shared frailty for clustering. RESULTS: Women in the intervention had increased LARC counseling, selection, and initiation, with similar effects among older adolescent and nulliparous women, and among young adult and parous women. Across study arms, older adolescents were as likely as young adults to receive LARC counseling (adjusted odds ratio [aOR] = .85; 95% confidence interval [CI]: .63-1.15), select LARC (aOR = .86; 95% CI: .64-1.17), and use LARC methods (adjusted hazard ratio [aHR] = .94; 95% CI: .69-1.27). Nulliparous women were less likely to receive counseling (aOR = .57; 95% CI: .42-.79) and to select LARC (aOR = .53; 95% CI: .37-.75) than parous women, and they initiated LARC methods at lower rates (aHR = .65; 95% CI: .48-.90). Nulliparous women had similar rates of implant initiation but lower rates of intrauterine device initiation (aHR = .59; 95% CI: .41-.85). CONCLUSIONS: Continued efforts should be made to improve counseling and access to LARC methods for nulliparous women of all ages.

Neurobiology of food addiction and adolescent obesity prevention in low- and middle-income countries.

Adolescent obesity has become an increasingly urgent issue in low- and middle-income countries. Recent relevant advances include the application of the neurobiology of addiction to food addiction and obesity. The biochemistry of the etiology of obesity indicates the need for multilevel interventions that go beyond simple behavioral approaches. Additional research on the neurobiology of food addiction and adolescent obesity in low- and middle-income countries, as well as program evaluations that examine the biochemical effects of complex interventions, is urgently needed.

Implications of science for illicit drug use policies for adolescents in low- and middle-income countries.

Advances in neuroscience have improved our knowledge of the impact of illicit drug use on the adolescent brain. Translating this new knowledge into improved policies and programs requires the participation of public health and social sciences. This article discusses the implications of the recent advances of neurobiology for policies especially as they pertain to adolescents in low- and middle-income countries. It includes an overview of adolescent use of illicit drugs in low- and middle-income countries and calls for a move toward a transdisciplinary approach. It presents some of the challenges for research aimed at increasing our understanding of the issue and for policy.