Balancing enhanced contraceptive access with risk of reproductive injustice: A United States comparative case study.

OBJECTIVE: We aimed to examine how peripartum contraceptive care quality improvement efforts address or perpetuate reproductive health injustices. STUDY DESIGN: We conducted a comparative case study of inpatient postpartum contraceptive care implementation in 2017 to 2018, using key informant interviews at 11 United States hospitals. After our primary analysis revealed tensions between enhancing access to contraceptive care and patient-centeredness, we conducted the current inductive content analysis guided by 4 questions developed post-hoc: (1) What are healthcare workers' aspirations for contraceptive quality improvement programs? (2) What are healthcare workers' biases regarding peripartum contraceptive care delivery? (3) Do care delivery processes center patients' needs? (4) Do healthcare workers recognize and engage with structural inequities? RESULTS: Seventy-eight key informants (i.e., clinicians, operations staff, administrators) participated. In nine study sites, we observed evidence of interviewees both mitigating and perpetuating reproductive injustice. Many aspired to provide compassionate, patient-centered care, avoid paternalism, and foster patient autonomy. Simultaneously, interviewees demonstrated biases, including implicit subscription to an ideology of stratified reproduction, stereotyping, and "othering." Even when interviewees endorsed goals of patient-centeredness, care delivery processes sometimes prioritized healthcare systems' needs, and patients were not included on quality improvement teams. Many interviewees recognized structural inequities as driving health outcome disparities, yet relied on individual-level solutions like long-acting reversible contraception, and not structural-level interventions, to address them. CONCLUSION: Alongside enthusiasm for delivering compassionate care exist biases, missed opportunities to center patients, and lack of curiosity about the appropriateness of solving structural-level problems with individual-level solutions. IMPLICATIONS: Our findings call for individual and institutional self-reflection, partnership with patients and communities, and other intentional efforts to mitigate potential for harm in initiatives enhancing access to contraceptive care.

Leveraging Administrative Claims to Understand Disparities in Gender Minority Health: Contraceptive Use Patterns Among Transgender and Nonbinary People.

Purpose: Transgender people face disparities in access to reproductive and sexual health services; however, differences in receipt of contraceptive services have not been quantified. We compare contraceptive patterns between cisgender women and trans masculine people in insurance claims databases. Methods: We analyzed 2014-2018 Truven MarketScan data, using diagnostic and procedural codes to identify sex assigned at birth, and existing coding methodology to identify transgender and nonbinary people. We compared contraceptive patterns between cisgender women and trans masculine people aged 15-49 in Medicaid and commercial databases. Results: We identified 4700 people in the commercial and 1628 people in the Medicaid databases as trans masculine. Trans masculine people were prescribed fewer oral contraceptive pills (Medicaid: 17.44%, commercial: 16.62%) compared to cisgender women (Medicaid: 24.96%, commercial: 27.85%), less long-acting reversible contraception (LARC) use (Medicaid: 7.62%, commercial: 7.49% vs. Medicaid: 12.79%, commercial: 8.51%), had more hysterectomies (Medicaid: 5.77%, commercial: 8.45% vs. Medicaid: 2.15%, commercial: 2.48%), and less evidence of any contraception (Medicaid: 34.21%, commercial: 32.28% vs. Medicaid: 46.80%, commercial: 39.81%). Hysterectomies and LARC use varied by insurance type. Conclusion: We found significant differences in contraceptive patterns between trans masculine people and cisgender women. Data suggest potential differences in hysterectomy occurrences by trans masculine people, and long-acting reversible contraceptive use by cisgender women, in Medicaid versus commercial insurance cohorts. Appropriate counseling, insurance coverage, and removal of structural barriers are needed to ensure adequate access to contraception methods for people of all genders-regardless of whether they are being employed for contraception, menstrual management, or gender affirmation.

South African abortion attitudes from 2007-2016: the roles of religiosity and attitudes toward sexuality and gender equality.

Abortion is legal in South Africa, but negative abortion attitudes remain common and are poorly understood. We used nationally representative South African Social Attitudes Survey data to analyze abortion attitudes in the case of fetal anomaly and in the case of poverty from 2007 to 2016 (n = 20,711; ages = 16+). We measured correlations between abortion attitudes and these important predictors: religiosity, attitudes about premarital sex, attitudes about preferential hiring and promotion of women, and attitudes toward family gender roles. Abortion acceptability for poverty increased over time (b = 0.05, p < .001), but not for fetal anomaly (b = -0.008, p = .284). Highly religious South Africans reported lower abortion acceptability in both cases (Odds Ratio (OR)anomaly = 0.85, p = .015; ORpoverty = 0.84, p = .02). Premarital sex acceptability strongly and positively predicted abortion acceptability (ORanomaly = 2.63, p < .001; ORpoverty = 2.46, p < .001). Attitudes about preferential hiring and promotion of women were not associated with abortion attitudes, but favorable attitudes about working mothers were positively associated with abortion acceptability for fetal anomaly ((ORanomaly = 1.09, p = .01; ORpoverty = 1.02, p = .641)). Results suggest negative abortion attitudes remain common in South Africa and are closely tied to religiosity, traditional ideologies about sexuality, and gender role expectations about motherhood.

Attitudes toward abortion, social welfare programs, and gender roles in the U.S. and South Africa.

Public abortion attitudes are important predictors of abortion stigma and accessibility, even in legal settings like the U.S. and South Africa. With data from the U.S. General Social Survey and South African Social Attitudes Survey, we used ordinal logistic regressions to measure whether abortion acceptability (in cases of poverty and fetal anomaly) is related to attitudes about social welfare programs and gender roles, then assessed differences by race/ethnicity and education. Social welfare program attitudes did not correlate with abortion acceptability in the U.S., but in South Africa, greater support for income equalization (OR: 0.59, 95% CI: 0.41-0.85) and increased government spending on the poor (OR: 0.66, 95% CI: 0.49-0.91) correlated with lower abortion acceptability in circumstances of poverty. This was significant for Black African and higher educated South Africans. In the U.S., egalitarian gender role attitudes correlated with higher acceptability of abortion in circumstances of poverty (OR: 1.18, 95% CI: 1.03-1.36) and fetal anomaly (OR: 1.15, 95% CI: 1.01-1.31). This was significant for White and less educated Americans. In South Africa, egalitarian gender role attitudes correlated with higher abortion acceptability for fetal anomaly (OR: 1.12, 95% CI: 1.01-1.25) overall and among Black and less educated respondents, but among non-Black South Africans they correlated with higher abortion acceptability in circumstances of poverty. These results suggest abortion attitudes are distinctly related to socioeconomic and gender ideology depending one's national context, race/ethnicity, and socioeconomic status. Reducing abortion stigma will require community-based approaches rooted in intersectional reproductive justice frameworks.

Bridging the Expertise of Advocates and Academics to Identify Reproductive Justice Learning Outcomes.

Phenomenon: Reproductive justice (RJ) is defined by women of color advocates as the right to have children, not have children and parent children while maintaining reproductive autonomy. In the United States, physicians have been complicit in multiple historical reproductive injustices, involving coercive sterilization of thousands of people of color, low income, and disabilities. Currently, reproductive injustices continue to occur; however, physicians have no formal RJ medical education to address injustices. The objective of this study was to engage leading advocates within the movement using a Delphi method to identify critical components for such a curriculum. Approach: In 2016, we invited 65 RJ advocates and leaders to participate in an expert panel to design RJ medical education. A 3-round Delphi survey was distributed electronically to identify content for inclusion in an RJ curriculum. In the next 2 survey rounds, experts offered feedback and revisions and rated agreement with including content recommendations in the final curriculum. We calculated descriptive statistics to analyze quantitative data. A team with educational expertise wrote learning outcomes based on expert content recommendations. Findings: Of the 65 RJ advocates and leaders invited, 41 participated on the expert panel of the Delphi survey. In the first survey, the expert panel recommended 58 RJ content areas through open-ended response. Over the next 2 rounds, there was consensus among the panel to include 52 of 58 of these areas in the curriculum. Recommended content fell into 11 broad domains: access, disparities, and structural competency; advocacy; approaches to reproductive healthcare; contemporary law and policy; cultural safety; historical injustices; lesbian, gay, bisexual, transgender, queer/questioning, and intersex health; oppression, power, and bias training; patient care; reproductive health; and RJ definitions. The 97 learning outcomes created from this process represented both unique and existing educational elements. Insights: A collaborative methodology infused with RJ values can bridge experts in advocacy and academics. New learning outcomes identified through this process can enhance medical education; however, it is just as important to consider education in RJ approaches to care as it is knowledge about that care. We must explore the pedagogic process of RJ medical education while considering that expertise in this area may exist outside of the medical community and thus there is a need to partner with RJ advocates. Finally, we expect to use innovative teaching methods to transform medical education and achieve an RJ focus.

Stigma and abortion complications: stories from three continents.

Complications from abortion, while rare, are to be expected, as with any medical procedure. While the vast majority of serious abortion complications occur in parts of the world where abortion is legally restricted, legal access to abortion is not a guarantee of safety, particularly in regions where abortion is highly stigmatised. Women who seek abortion and caregivers who help them are universally negatively "marked" by their association with abortion. While attention to abortion stigma as a sociological phenomenon is growing, the clinical implications of abortion stigma - particularly its impact on abortion complications - have received less consideration. Here, we explore the intersections of abortion stigma and clinical complications, in three regions of the world with different legal climates. Using narratives shared by abortion caregivers, we conducted thematic analysis to explore the ways in which stigma contributes, both directly and indirectly, to abortion complications, makes them more difficult to treat, and impacts the ways in which they are resolved. In each narrative, stigma played a key role in the origin, management and outcome of the complication. We present a conceptual framework for understanding the many ways in which stigma contributes to complications, and the ways in which stigma and complications reinforce one another. We present a range of strategies to manage stigma which may prove effective in reducing abortion complications.

Looking back while moving forward: a justice-based, intersectional approach to research on contraception and disability.

For the first time in the 21st century, we have an emerging body of research regarding contraceptive use among adult women with disabilities in the United States. We highlight key findings from population-based analyses that found higher odds of female sterilization and lower odds of long-acting reversible contraception use among women with disabilities compared to their peers without disabilities. We consider potential reasons underlying these differences, including discriminatory attitudes and policies that restrict the sexual and reproductive autonomy of people with disabilities. We advocate for a justice-based, intersectional approach to research on contraception and disability with the aim of promoting the reproductive autonomy of people with disabilities.

Factors associated with sexual and reproductive health stigma among adolescent girls in Ghana.

OBJECTIVE: Using our previously developed and tested Adolescent Sexual and Reproductive Health (SRH) Stigma Scale, we investigated factors associated with perceived SRH stigma among adolescent girls in Ghana. METHODS: We drew upon data from our survey study of 1,063 females 15-24yrs recruited from community- and clinic-based sites in two Ghanaian cities. Our Adolescent SRH Stigma Scale comprised 20 items and 3 sub-scales (Internalized, Enacted, Lay Attitudes) to measure stigma occurring with sexual activity, contraceptive use, pregnancy, abortion and family planning service use. We assessed relationships between a comprehensive set of demographic, health and social factors and SRH Stigma with multi-level multivariable linear regression models. RESULTS: In unadjusted bivariate analyses, compared to their counterparts, SRH stigma scores were higher among girls who were younger, Accra residents, Muslim, still in/dropped out of secondary school, unemployed, reporting excellent/very good health, not in a relationship, not sexually experienced, never received family planning services, never used contraception, but had been pregnant (all p-values <0.05). In multivariable models, higher SRH stigma scores were associated with history of pregnancy (ß = 1.53, CI = 0.51,2.56) and excellent/very good self-rated health (ß = 0.89, CI = 0.20,1.58), while lower stigma scores were associated with older age (ß = -0.17, 95%CI = -0.24,-0.09), higher educational attainment (ß = -1.22, CI = -1.82,-0.63), and sexual intercourse experience (ß = -1.32, CI = -2.10,-0.55). CONCLUSIONS: Findings provide insight into factors contributing to SRH stigma among this young Ghanaian female sample. Further research disentangling the complex interrelationships between SRH stigma, health, and social context is needed to guide multi-level interventions to address SRH stigma and its causes and consequences for adolescents worldwide.

Harm Reduction for Abortion in the United States.

Access to abortion in the United States has eroded significantly. Accordingly, there is a growing movement to empower women to self-induce abortion. To date, physicians' roles and responsibilities in this changing environment have not been defined. Here, we consider a harm reduction approach to first-trimester abortion as a way for physicians to honor clinical and moral obligations to care for women, negotiate ever-increasing abortion restrictions, and support women who consider abortion self-induction. Harm reduction approaches to abortion have been successfully implemented in a range of countries around the world and typically take the form of teaching women how to use misoprostol. When women self-administer misoprostol, rather than resort to other means such as self-instrumentation or abdominal trauma, to end a pregnancy, maternal mortality falls. There are clinical and ethical benefits as well as limitations to a harm reduction approach to abortion in U.S. SETTINGS: Its legal implications for patients and physicians are unclear. Ultimately, we suggest that despite its limitations, a harm reduction approach may help both physicians and patients.

Stratified reproduction, family planning care and the double edge of history.

PURPOSE OF REVIEW: There is a growing clinical consensus that Medicaid sterilization consent protections should be revisited because they impede desired care for many women. Here, we consider the broad social and ideological contexts for past sterilization abuses, beyond informed consent. RECENT FINDINGS: Throughout the US history, the fertility and childbearing of poor women and women of color were not valued equally to those of affluent white women. This is evident in a range of practices and policies, including black women's treatment during slavery, removal of Native children to off-reservation boarding schools and coercive sterilizations of poor white women and women of color. Thus, reproductive experiences throughout the US history were stratified. This ideology of stratified reproduction persists today in social welfare programs, drug policy and programs promoting long-acting reversible contraception. SUMMARY: At their core, sterilization abuses reflected an ideology of stratified reproduction, in which some women's fertility was devalued compared to other women's fertility. Revisiting Medicaid sterilization regulations must therefore put issues of race, ethnicity, class, power and resources - not just informed consent - at the center of analyses.

Disparities in abortion rates: a public health approach.

Women of lower socioeconomic status and women of color in the United States have higher rates of abortion than women of higher socioeconomic status and White women. Opponents of abortion use these statistics to argue that abortion providers are exploiting women of color and low socioeconomic status, and thus, regulations are needed to protect women. This argument ignores the underlying causes of the disparities. As efforts to restrict abortion will have no effect on these underlying factors, and instead will only result in more women experiencing later abortions or having an unintended childbirth, they are likely to result in worsening health disparities. We provide a review of the causes of abortion disparities and argue for a multifaceted public health approach to address them.

Abortion politics and the production of knowledge.

It is common to think of scientific research and the knowledge it generates as neutral and value free. Indeed, the scientific method is designed to produce "objective" data. However, there are always values built into science, as historians of science and technology have shown over and over. The relevant question is not how to rid science of values but, instead, to ask which values and whose values belong? Currently, antiabortion values consistently determine US research policy. Abortion research is declared illegitimate in covert and overt ways, at the level of individual researchers and research policy broadly. Most importantly, federal policy impedes conduct of both basic and clinical research in abortion. However, it is not just research in abortion that is deemed "illegitimate;" research in infertility and in vitro fertilization is as well. Federal funding of any reproductive health research agenda that would pose more than minimal risk to a fetus or embryo is banned. This leaves unanswered scientific questions about abortion, infertility, miscarriage and contraception among other areas. Since moral ground is occupied not just by abortion opponents but also by people who support abortion rights, there is at the very least a competing moral claim to consider changing federal research funding policy. Women and families deserve access to knowledge across the spectrum of reproductive health issues, whether they seek to end or start a pregnancy. Thus, research funding is an issue of reproductive justice.

Treatment patterns for early pregnancy failure in Michigan.

AIMS: We describe current treatment patterns for early pregnancy failure (EPF) among women enrolled in two Michigan health plans. METHODS: We conducted a retrospective review of EPF treatment among Michigan Medicaid enrollees between January 1, 2001, and December 31, 2004, and enrollees of a university-affiliated health plan between January 1, 2001, and December 31, 2005. Episodes were identified by the presence of a diagnostic code for EPF. Surgical treatment was distinguished from nonsurgical management using procedure codes. Facility charges, procedure, and place of service codes were used to determine whether a procedure was done in an office as opposed to an operating room. Cases without a claim for surgical uterine evacuation were examined for a misoprostol pharmacy claim and, if present, were classified as medical management. Cases without a procedure or pharmacy claim were classified as expectant management. RESULTS: Respectively, we identified 21,311 and 1,493 episodes of EPF in the Medicaid and university-affiliated health plan databases, respectively. Women enrolled in Medicaid were more likely to be treated with surgery than were enrollees of the university-affiliated health plan (35.3 vs. 18.0%, respectively, p < 0.000). Among Medicaid enrollees, only 0.5% of surgical evacuations occurred in the office, but office procedures were common among enrollees of the university-affiliated health plan (30.5%, p < 0.000). The proportion of cases managed with misoprostol was <1% in both groups. Caucasian race and age were both associated with having a surgical uterine evacuation (p < 0.001). CONCLUSIONS: EPF is primarily being treated with expectant management or surgical evacuation in an operating room and may not reflect evidence-based practices or patient preferences.

Mode of delivery: toward responsible inclusion of patient preferences.

Deciding when and how to incorporate patient preferences regarding mode of delivery is challenging for both obstetric providers and policymakers. An analysis of current guidelines in four clinical scenarios (prior cesarean, twin delivery, breech presentation, and maternal request for cesarean) indicates that some guidelines are highly prescriptive whereas others are more flexible, based on physicians' discretion or (less frequently) patient preferences, without consistency or explicit rationale for when such flexibility is permissible, advisable, or obligatory. Although patient-choice advocates have called for more patient-responsive guidelines, concerns also have been raised, especially in the context of discussions of cesarean delivery on maternal request, about the dangers of unfettered patient-preference-driven clinical decisions. In this article, we outline a framework for the responsible inclusion of patient preferences into decision making regarding approach to delivery. We conclude, using this framework, that more explicit incorporation of patient preferences is called for in the first three scenarios and indicate why expanding access to cesarean delivery on maternal request is more complicated and would require more data and further consideration.

Surgical management of early pregnancy failure: history, politics, and safe, cost-effective care.

Early pregnancy failure and induced abortion are often managed differently, even though safe uterine evacuation is the goal in both. Early pregnancy failure is commonly treated by curettage in operating room settings in anesthetized patients. Induced abortion is most commonly managed by office vacuum aspiration in awake or sedated patients. Medical evidence does not support routine operating room management of early pregnancy failure. This commentary reviews historical origins of these different care standards, explores political factors responsible for their perpetuation, and uses experience at University of Michigan to dramatize the ways in which history, politics, and biomedicine intersect to produce patient care. The University of Michigan initiated office uterine evacuations for early pregnancy failure treatment. Patients previously went to the operating room. These changes required faculty, staff, and resident education. Our efforts blurred the lines between spontaneous and induced abortion management, improved patient care and better utilized hospital resources.