Supporting Birthing People and Supporting Doulas: The Impact of the COVID-19 Pandemic on a Community-Based Doula Organization in San Francisco.

Background: Beginning in March 2020, health care systems in the United States restricted the number of support people who could be present during pregnancy-related care to reduce the spread of COVID-19. We aimed to describe how SisterWeb, a community-based doula organization that employs Black, Pacific Islander, and Latinx doulas in San Francisco, California, adapted to the COVID-19 pandemic. Methods: As part of process and outcome evaluations conducted through an academic-community partnership, we interviewed SisterWeb doulas, mentors, and leaders in 2020, 2021, and 2022 (n=26 interviews). We identified preliminary themes using the Rapid Assessment Process and then conducted thematic analysis of data related to COVID-19. Results: SisterWeb leadership remained committed to safeguarding doulas by shifting to virtual support until doulas were onboarded as benefitted employees. Doulas reported hospital policies impacted clients' pregnancy-related care. Initially, doulas adapted to virtual support by connecting with clients more frequently through phone and text. When permitted to meet in person, doulas adjusted to client preference. Finally, as the pandemic impacted doulas' well-being, they turned to mentors for emotional support. Discussion and Health Equity Implications: This analysis contributes to a growing body of literature describing doulas' experiences during the pandemic. By shifting to virtual support, SisterWeb leaders prioritized the health, safety, and financial stability of doulas, who were members of communities disproportionately impacted by COVID-19. Our findings suggest that public health guidance, organizational COVID-19 precautions, and hospital policies hindered SisterWeb's goal of ensuring clients receive equitable medical care. In addition, we found that emotional support for doulas is vital to their work.

What, when, and how long? Doula time use in a community doula program in San Francisco, California.

OBJECTIVES: Community doulas, who provide culturally concordant, nonclinical support during and after pregnancy, are increasingly promoted as an evidence-based intervention to advance birth equity. As valued members of their communities, community doulas often provide extensive physical and emotional pregnancy, birth, and postpartum support at low or no cost to clients. However, neither community doulas' scope of work nor the distribution of time among their different work activities has been clearly defined or enumerated; therefore, this project sought to describe the work activities and time use of doulas in one community-based doula organization. METHODS: In a quality improvement project, we reviewed case management system client data and collected 1 month of time diary data from eight doulas employed full-time at SisterWeb San Francisco Community Doula Network. We calculated descriptive statistics for activities community doulas reported in their time diaries and each visit/interaction logged in the case management system. RESULTS: SisterWeb doulas spent about half of their time in direct client care. For every hour that doulas spent with a client in prenatal and postpartum visits, on average, they spent an additional 2.15 h communicating with and supporting their clients in other ways. Overall, we estimate that SisterWeb doulas spend an average of 32 h providing care for a client receiving the standard course of care, including intake, prenatal visits, support during childbirth, and postpartum visits. CONCLUSIONS: Results highlight the wide variety of work that SisterWeb community doulas do beyond direct client care. Acknowledgment of community doulas' broad scope of work and appropriate compensation for all activities is necessary if doula care is to be advanced as a health equity intervention.

Community perspectives on pharmacist-prescribed hormonal contraception in rural California.

OBJECTIVES: In the United States, numerous states have enabled pharmacists to prescribe hormonal contraception. Little research focuses on the perspectives of potential users of this service in rural communities. This study sought to describe awareness of, interest in, acceptability of, and support for pharmacist-prescribed contraception in a rural California county. STUDY DESIGN: We conducted a community-based survey in 2019-20 in Tulare County, California. Researchers partnered with community members to design, implement, and analyze the survey. We recruited respondents who were ages 15 to 44 and assigned female sex at birth, using passive community-based approaches, social media advertisements, and social networks. Analyses focused on 177 respondents with a potential future need for contraception. RESULTS: Thirty-one percent of respondents were aware that pharmacists could prescribe hormonal contraception in California, with more accurate knowledge among older respondents (p = 0.015). After receiving brief educational information about pharmacist-prescribed contraception, respondents expressed high levels of support and acceptability: they perceived pharmacist-prescribed contraception to be safe, time saving, and more convenient. Respondents were more comfortable talking about contraception with traditional contraceptive care providers compared to asking pharmacists questions about contraception. Fifty-seven percent were somewhat or very interested in obtaining contraception from a pharmacist, with higher levels of interest among those who preferred to use a different method. CONCLUSION: Awareness of pharmacist-prescribed contraception in a rural California community was low, though people are supportive of and interested in utilizing this service. This research suggests that increased availability of pharmacist-prescribed contraception could support individuals' reproductive self-determination and address gaps in access. IMPLICATIONS: Despite limited awareness of pharmacist-prescribed contraception, interest in using and community support for this service was high in a rural California community. This analysis suggests that increased availability of pharmacist-prescribed contraception could support reproductive self-determination and address access barriers, particularly for people whose contraceptive needs are not currently being met.

Financial Strain and Contraceptive Use Among Women in the United States: Differential Effects by Age.

INTRODUCTION: Low-income and young women experience disproportionately high rates of unintended pregnancy. Traditional measures of socioeconomic status may not be appropriate indicators of financial status, particularly during emerging adulthood. This study investigates the relationship between financial strain and contraceptive use, focusing on the differential effects by age group. METHODS: Multinomial logistic regression analyses assessed the relationship between financial strain and contraceptive use in a national sample of U.S. women ages 18-39 years (N = 932). Models were adjusted for income, employment status, and other sociodemographic characteristics and tested the interaction of financial strain and age group. RESULTS: Women with high financial strain were less likely to use short-acting methods (compared with using no method) in the adjusted model; when the age and financial strain interaction was included, associations held only for women ages 18-24 and 25-29 years of age. Relative to contraceptive nonuse, women ages 18-24 years with high financial strain were less likely to use long-acting reversible (relative risk ratio [RRR], 0.10; 95% confidence interval [CI], 0.01-0.99) and short-acting hormonal (RRR, 0.03; 95% CI, 0.00-0.18) methods. Women ages 25-29 with high financial strain were less likely to use short-acting hormonal (RRR, 0.20; 95% CI, 0.05-0.87) and coital-specific (RRR, 0.11; 95% CI, 0.02-0.51) methods. IMPLICATIONS FOR PRACTICE AND/OR POLICY: Young women may be vulnerable to the effect of high financial strain on contraceptive nonuse. Providers working with this group should consider incorporating financial strain into screening tools to identify patients who may need extra attention in contraceptive decision-making conversations. Antipoverty programs could also have a positive effect on effective contraceptive use.

Evaluating the feasibility and acceptability of sending pregnancy and abortion history surveys through SMS text messaging to help reach sustainable development goal 3.

INTRODUCTION: In Kenya, abortion is illegal under most circumstances, yet about 48 abortions per 1,000 women occurred in 2012. Given the stigma around abortion, little is known about the availability of safe abortion. Thus, we explored the feasibility and acceptability of using SMS mobile surveys to collect information about women's pregnancy and abortion histories in Kenya. METHODS: We sent a one-time mobile survey to 500 18-24year old women who had opted-in to a 16,000-person mobile survey panel. Women elected to answer questions about pregnancy only (number of pregnancies, number of births, age at first pregnancy) or pregnancy and abortion (ever tried to obtain an abortion and whether medical treatment was sought for any complications). The final question for all survey versions was an open-ended question asking respondents how they felt answering these questions. RESULTS: 356 (71%) responded to the initial survey question and 333 (94%) consented to answer questions about pregnancy. Of these, 233 (70%) agreed to answer questions about just pregnancy and 76 (23%) agreed to answer questions about pregnancy and abortion. Three-quarters of respondents indicated that they had positive or neutral feelings about answering these questions over SMS. Lastly, all data was retrieved within 24h of survey distribution allowing for immediate analysis and dissemination. CONCLUSION: Women's willingness to share their pregnancy history suggests mobile surveys are a cost-effective and accessible method for gathering information on abortion in Kenya.

Preferences for a potential longer-acting injectable contraceptive: perspectives from women, providers, and policy makers in Kenya and Rwanda.

BACKGROUND: Between 1995 and 2005, injectable use doubled worldwide. However, discontinuation rates remain high, partly because of side effects but also because of missed appointments for reinjection. A longer-acting injectable (LAI) may improve compliance by reducing the required number of reinjection visits, thereby reducing unintentional discontinuation. This study examined acceptability of LAI characteristics comprising the target product profile (TPP). METHODS: In 2012, we conducted qualitative case studies in Kenya and Rwanda, consisting of 19 focus group discussions (FGDs) with 177 current, previous, or never users of injectables and 46 in-depth interviews (IDIs) with providers, program implementers, and policy makers. FGDs and IDIs assessed current injectable experiences; attitudes toward potential LAI products; and perceptions of TPP attributes, including ranking preferences for the most and least important characteristics. In addition, we obtained completed electronic surveys from 28 international family planning opinion leaders about the perceived need for an LAI, important product characteristics, and challenges to LAI development or introduction. RESULTS: Many FGD participants and interviewees spontaneously expressed strong interest in an LAI, but there was some variation in TPP preferences. The majority of participants ranked effectiveness as the most important TPP attribute. Providers were generally more concerned about side effects than potential users; some potential users suggested that side effects were related less to the product than to their own body chemistry and that side effects were acceptable as long as they did not last a long time or disrupt daily activities. Women and providers, especially in Kenya, preferred a method with a predictable return to fertility. Some participants associated amenorrhea with delayed or reduced fertility. Most women and providers preferred delivery of the LAI in a single, prepackaged, disposable injection system to facilitate injections by providers and to reduce the risk of pain or discomfort for women. While providers and policy makers ranked cost as one of the most important issues, it was among the least important issues for most potential users. Many Kenyan, but few Rwandan, participants appeared willing to pay for an LAI, with some presuming cost savings from reduced menstruation and fewer clinic visits. CONCLUSIONS: Some TPP preferences for an LAI have implications for product development decisions about formulation, delivery mechanism, or presentation, while others point to the need for tailored communication and counseling approaches to ensure acceptability and adherence within clinical trials and beyond.

Policy and programmatic considerations for introducing a longer-acting injectable contraceptive: perspectives of stakeholders from Kenya and Rwanda.

BACKGROUND: More than 40 million women use injectable contraceptives to prevent pregnancy, and most current or previous injectable users report being satisfied with the method. However, while women may find injectables acceptable, they may not always find them accessible due to stock-outs and difficulties with returning to the clinic for reinjections. FHI 360 is spearheading efforts to develop a longer-acting injectable (LAI) contraceptive that could provide at least 6 months of protection against pregnancy. This article addresses systems-level considerations for the introduction of a new LAI. METHODS: We conducted qualitative case studies in Kenya and Rwanda-two countries that have high levels of injectable use but with different service delivery contexts. Between June and September 2012, we conducted in-depth interviews with 27 service providers and 19 policy makers and program implementers focusing on 4 themes: systems-level barriers and facilitators to delivering LAI services; process for introducing an LAI; LAI distribution approaches; and potential LAI characteristics. We also obtained electronic feedback from 28 international family planning opinion leaders. RESULTS: Respondents indicated strong interest in an LAI and thought it would appeal to existing injectable users as well as new family planning clients, both for spacing and for limiting births. Providers appreciated the potential for a lighter workload due to fewer follow-up visits, but they were concerned that fewer visits would also decrease their ability to help women manage side effects. The providers also appreciated the 1-month grace period for follow-up LAI injections; some seemed unaware of the latest international guidance that had increased the grace period from 2 weeks to 4 weeks for the currently available 3-month injectable. The majority of policy makers and program implementers were supportive of letting community health workers provide the method, but many nurses and midwives in Kenya had reservations about the approach. At the policy level, respondents indicated that obtaining regulatory approvals before introducing the new method could be costly and time-consuming. Manufacturing and procurement decisions could also affect cost and availability. CONCLUSIONS: Successful introduction of a potential longer-acting injectable may be enhanced by considering broader systemic issues, including managing cost to the health system and users, expanding access through community-based distribution, and training providers on the latest service delivery guidelines.