Implementation science: Scaling a training intervention to include IUDs and implants in contraceptive services in primary care.

Building capacity for contraceptive services in primary care settings, including for intrauterine devices (IUDs) and implants, can help to broaden contraceptive access across the US. Following a randomized trial in family planning clinics, we brought a provider training intervention to other clinical settings including primary care in all regions. This implementation science study evaluates a national scale-up of a contraceptive training intervention to varied practice settings from 2013 to 2019 among 3216 clinic staff serving an estimated 1.6 million annual contraceptive patients. We measured providers' knowledge and clinical practice changes regarding IUDs and implants using survey data. We estimated the overall intervention effect, and its relative effectiveness in primary care settings, with generalized estimating equations for clustered data. Patient-centered counseling improved, along with comfort with method provision and removal. Provider knowledge increased (p < 0.001), as did evidence-based counseling for IUDs (aOR 3.3 95% CI 2.8-3.9) and implants (aOR 3.5, 95% CI 3.0-4.1), and clinician competency in copper and levonorgestrel IUDs (aORs 1.8-2.6 95% CIs 1.5-3.2) and implants (aOR 2.4 95% CI 2.0-2.9). While proficiency was lower initially in primary care, gains were significant and at times greater than in Planned Parenthood health clinics. This intervention was effectively scaled, including in primary care settings with limited prior experience with these methods. Recent changes to Title X family planning funding rules exclude several large family planning providers, shifting greater responsibility to primary care and other settings. Scaling effective contraceptive interventions is one way to ensure capacity to offer patients full contraceptive services.

Human epidermal neural crest stem cells as a source of Schwann cells.

We show that highly pure populations of human Schwann cells can be derived rapidly and in a straightforward way, without the need for genetic manipulation, from human epidermal neural crest stem cells [hEPI-NCSC(s)] present in the bulge of hair follicles. These human Schwann cells promise to be a useful tool for cell-based therapies, disease modelling and drug discovery. Schwann cells are glia that support axons of peripheral nerves and are direct descendants of the embryonic neural crest. Peripheral nerves are damaged in various conditions, including through trauma or tumour-related surgery, and Schwann cells are required for their repair and regeneration. Schwann cells also promise to be useful for treating spinal cord injuries. Ex vivo expansion of hEPI-NCSC isolated from hair bulge explants, manipulating the WNT, sonic hedgehog and TGFß signalling pathways, and exposure of the cells to pertinent growth factors led to the expression of the Schwann cell markers SOX10, KROX20 (EGR2), p75NTR (NGFR), MBP and S100B by day 4 in virtually all cells, and maturation was completed by 2 weeks of differentiation. Gene expression profiling demonstrated expression of transcripts for neurotrophic and angiogenic factors, as well as JUN, all of which are essential for nerve regeneration. Co-culture of hEPI-NCSC-derived human Schwann cells with rodent dorsal root ganglia showed interaction of the Schwann cells with axons, providing evidence of Schwann cell functionality. We conclude that hEPI-NCSCs are a biologically relevant source for generating large and highly pure populations of human Schwann cells.

The impact of an IUD and implant intervention on dual method use among young women: Results from a cluster randomized trial.

Long-acting reversible contraceptives (LARCs) are highly effective at preventing pregnancy but do not protect against sexually transmitted infection (STI). Recent efforts to improve access to intrauterine devices (IUDs) and implants have raised concerns about STI prevention and reduced condom use, particularly among teenagers and young women. We evaluated whether a provider-targeted intervention to increase LARC access negatively impacted dual method use and STI incidence among an at-risk patient population. We conducted a cluster randomized trial in 40 reproductive health centers across the United States from May 2011 to May 2013. After training providers at 20 intervention sites, we recruited 1500 sexually-active women aged 18-25years who did not desire pregnancy and followed them for one year. We assessed intervention effects on dual method use, condom use and STI incidence, modeling dual method use with generalized estimating equations and STI incidence with Cox proportional hazard regression models, accounting for clustering. We found no differences between intervention and control groups in dual method use (14.3% vs. 14.4%, aOR 1.03, 95% CI 0.74-1.44) or condom use (30% vs. 31%, aOR 1.03, 95% CI 0.79-1.35) at last sex at one year. STI incidence was 16.5 per 100 person-years and did not differ between intervention and control groups (aHR 1.20, 95% CI 0.88-1.64). A provider training intervention to increase LARC access neither compromised condom use nor increased STI incidence among young women. Dual method use was very low overall, highlighting the need to bolster STI prevention efforts among adolescents and young women.

Public Funding for Contraception, Provider Training, and Use of Highly Effective Contraceptives: A Cluster Randomized Trial.

OBJECTIVES: We determined whether public funding for contraception was associated with long-acting reversible contraceptive (LARC) use when providers received training on these methods. METHODS: We evaluated the impact of a clinic training intervention and public funding on LARC use in a cluster randomized trial at 40 randomly assigned clinics across the United States (2011-2013). Twenty intervention clinics received a 4-hour training. Women aged 18 to 25 were enrolled and followed for 1 year (n = 1500: 802 intervention, 698 control). We estimated the effects of the intervention and funding sources on LARC initiation with Cox proportional hazards models with shared frailty. RESULTS: Women at intervention sites had higher LARC initiation than those at control (22 vs 18 per 100 person-years; adjusted hazard ratio [AHR] = 1.43; 95% confidence interval [CI] = 1.04, 1.98). Participants receiving care at clinics with Medicaid family planning expansion programs had almost twice the initiation rate as those at clinics without (25 vs 13 per 100 person-years; AHR = 2.26; 95% CI = 1.59, 3.19). LARC initiation also increased among participants with public (AHR = 1.56; 95% CI = 1.09, 2.22) but not private health insurance. CONCLUSIONS: Public funding and provider training substantially improve LARC access.

Service provider perspectives on post-abortion contraception in Nepal.

The government of Nepal has articulated a commitment to the provision of post-abortion contraception since the implementation of a legal safe abortion policy in 2004. Despite this, gaps in services remain. This study examined the perspectives of abortion service providers and administrators regarding strengths and shortcomings of post-abortion contraceptive service provision. In-depth interviews were conducted with 24 abortion providers and administrators at four major health facilities that provide legal abortion in Nepal. Facility factors perceived to impact post-abortion contraceptive services included on-site availability of contraceptive supplies, dedicated and well-trained staff and adequate infrastructure. Cultural norms emerged as influencing contraceptive demand by patients, including method use being unacceptable for women whose husbands migrate and limited decision-making power among women. Service providers described their personal views on appropriate childbearing and the use of specific contraceptive methods that influenced counselling. Findings suggest that improvements to a facility's infrastructure and training to address provider biases and misinformation may improve post-abortion family planning uptake. Adapting services to be sensitive to cultural expectations and norms may help address some barriers to contraceptive use. More research is needed to determine how to best meet the contraceptive needs of women who have infrequent sexual activity or who may face stigma for using family planning, including adolescents, unmarried women and women whose husbands migrate.

Human epidermal neural crest stem cells as candidates for cell-based therapies, disease modeling, and drug discovery.

In this review article I explore the suitability of human epidermal neural crest stem cells (hEPI-NCSC) for translational medicine. hEPI-NCSC are multipotent somatic stem cells that are derived from the embryonic neural crest. hEPI-NCSC are located in the bulge of hair follicles where they persist postnatally and into adulthood. Because of their location in the hairy skin and their migratory behavior, hEPI-NCSC can be easily isolated as a highly pure population of stem cells without the need for purification. Furthermore they can be expanded ex vivo into millions of stem cells, they do not form tumors in vivo, and they can undergo directed differentiation into crest and noncrest-derived cell types of clinical relevance. Taken together, these characteristics make hEPI-NCSC attractive candidates for cell-based therapies, drug discovery, and disease modeling.

Provision of DMPA-SC for self-administration in different practice settings during the COVID-19 pandemic: Data from providers across the United States.

OBJECTIVES: Depot medroxyprogesterone acetate-subcutaneous (DMPA-SC) can be prescribed through telemedicine and self-administered, but data about availability, particularly during the COVID-19 pandemic, are limited. This study assessed changes in the availability of DMPA-SC for self-administration during the pandemic. STUDY DESIGN: This study used survey data from a convenience sample of US providers engaged in contraceptive care and participating in a Continuing Medical Education-accredited contraceptive training (April 2020-April 2022; n = 849). Providers were recruited from across 503 clinics, including primary care and family planning clinics, public health departments, college and school-based health centers, independent abortion care clinics, and outpatient clinics in hospital settings. Measures included the availability of DMPA-SC for self-administration before and during the pandemic and the use of telemedicine. We used Poisson regression models and cluster-robust errors by clinic, adjusting for region, time of survey, and clinic size, to assess clinic availability of DMPA-SC for self-administration by practice setting. RESULTS: Compared to the prepandemic period (4%), the availability of DMPA-SC for self-administration increased significantly during the pandemic (14%) (adjusted prevalence ratios [aPR] 3.43, 95% CI [2.43-4.85]). During the pandemic, independent abortion clinics were more likely to offer DMPA-SC for self-administration compared to primary care clinics (aPR 2.44, 95% CI [1.10-5.41]). Clinics receiving Title X funds were also more likely to provide DMPA-SC for self-administration during the pandemic compared to other clinics (aPR 2.32, 95% CI [1.57-3.43]), and more likely to offer DMPA-SC for self-administration through telemedicine (aPR 2.35, 95% CI [1.52-3.63]). Compared to the early pandemic period (April-September 2022), telemedicine access to DMPA-SC for self-administration was highest during the later pandemic time period (October 2021-April 2022) (aPR 2.10, 95% CI [1.06-4.17]). CONCLUSIONS: The availability of DMPA-SC for self-administration significantly increased during the pandemic with differences by practice setting and Title X funding. However, overall method availability remains persistently low. IMPLICATIONS: Despite increased availability of DMPA-SC for self-administration among US contraceptive providers during the COVID-19 pandemic, there remains a need to train providers, educate patients, and remove barriers to ensure broader availability of this method across different practice settings.

Counseling and provision of long-acting reversible contraception in the US: national survey of nurse practitioners.

OBJECTIVE: Nurse practitioners (NPs) provide frontline care in women's health, including contraception, an essential preventive service. Their importance for contraceptive care will grow, with healthcare reforms focused on affordable primary care. This study assessed practice and training needs to prepare NPs to offer high-efficacy contraceptives - intrauterine devices (IUDs) and implants. METHOD: A US nationally representative sample of nurse practitioners in primary care and women's health was surveyed in 2009 (response rate 69%, n=586) to assess clinician knowledge and practices, guided by the CDC US Medical Eligibility Criteria for Contraceptive Use. RESULTS: Two-thirds of women's health NPs (66%) were trained in IUD insertions, compared to 12% of primary care NPs. Contraceptive counseling that routinely included IUDs was low overall (43%). Nurse practitioners used overly restrictive patient eligibility criteria, inconsistent with CDC guidelines. Insertion training (aOR=2.4, 95%CI: 1.10 5.33) and knowledge of patient eligibility (aOR=2.9, 95%CI: 1.91 4.32) were associated with IUD provision. Contraceptive implant provision was low: 42% of NPs in women's health and 10% in primary care. Half of NPs desired training in these methods. CONCLUSION: Nurse practitioners have an increasingly important position in addressing high unintended pregnancy in the US, but require specific training in long-acting reversible contraceptives.

"She should support me, she's my doctor:" Patient perceptions of agency in contraceptive decision-making in the clinical encounter in Northern California.

INTRODUCTION: Agency in contraceptive decision-making is an essential aspect of reproductive autonomy. We conducted qualitative research to investigate what agency means to patients seeking contraceptive care to inform the development of a validated measure of this construct. METHODOLOGY: We held four focus group discussions and seven interviews with sexually-active individuals assigned female at birth, ages 16-29 years, recruited from reproductive health clinics in Northern California. We explored experiences in contraceptive decision-making during the clinic visit. We coded data in ATLAS.ti and by hand, compared codes across three coders, and used thematic analysis to identify salient themes. RESULTS: The sample mean age was 21 years, with 17% of participants identifying as Asian, 23% as Black, 27% as Latinx, 17% as Multiracial/other, and 27% as white. Overall, participants reported active and engaged decision-making in their recent contraceptive visit but noted experiences that had undermined their agency in the past. They described how non-judgmental care allowed them to communicate openly, affirming their ability to make their own decisions. However, several mentioned how unexpected contraceptive side effects after the visit had reduced their sense of agency over their decision in retrospect. Several participants, including those who identified as Black, Latinx, and/or Asian, described prior experiences where pressure to use a contraceptive method had undermined their agency and where they had switched providers to regain agency over their contraceptive decisions. DISCUSSION: Most participants were aware of their agency during contraceptive visits and how it varied in different experiences with providers and the healthcare system. Patient perspectives can help to inform measurement development and ultimately the delivery of care that supports contraceptive agency.

Male circumcision for HIV prevention: clinical practices and attitudes among healthcare providers in South Africa and Zimbabwe.

BACKGROUND: This study aimed to document the clinical practices and attitudes of health care providers in South Africa and Zimbabwe on male circumcision for human immunodeficiency virus (HIV) prevention. METHODS: We conducted national surveys of physicians and nurses in both countries in 2008-2009 (N = 1444). Data on male circumcision for HIV prevention were analyzed; outcomes were patient counseling, provision of services, and desire for training. We used multivariable logistic regression to examine associations between these outcomes and clinician, practice, and attitudinal variables. RESULTS: Overall, 57% of clinicians reported counseling male patients on male circumcision, 17% were offering services (49% referrals), and 61% desired training. In the multivariable analyses, provision of services was more common in South Africa (P ≤ 0.001) but desire for training higher in Zimbabwe (P ≤ 0.01). Provision of services was highest among physicians (P ≤ 0.01) and in hospital settings (P ≤ 0.001). However, nurses had greater desire for training (P ≤ 0.05) as did younger clinicians (P ≤ 0.001). Clinicians in rural and clinic settings were just as likely to express training interest. Clinician attitudes that patients would be upset due to cultural beliefs and would increase risky behaviors were associated with less counseling and service provision (P ≤ 0.05). CONCLUSIONS: Many clinicians in South Africa and Zimbabwe showed willingness to integrate new HIV prevention evidence into practice and to become trained to offer the procedure to patients. Results suggest that both countries should consider involving nurses in male circumcision for HIV prevention, including those in rural areas, and should help clinicians to address cultural concerns.

Willingness of clinicians to integrate microbicides into HIV prevention practices in southern Africa.

The first vaginal microbicide was recently proven effective in clinical trials. We assessed the willingness of clinicians to integrate microbicides into HIV prevention practices in Southern Africa, where women face elevated HIV risks. We conducted in-depth interviews (n = 60) and nationally representative surveys (n = 1,444) in South Africa and Zimbabwe with nurses and physicians. Over half of clinicians (58%) were aware of microbicides, with physicians far more likely than nurses to be familiar. Clinicians, including those in rural areas, were generally willing to discuss microbicides, a female-initiated method less effective than the condom, particularly when condom use was unlikely (70%). Fewer would include microbicides while counseling adolescents (51%). Most clinicians (85%) thought their patients would use microbicides; greater clinician familiarity with microbicides was significant for support. Training for both nurses and physicians prior to introduction is critical, so they have sufficient knowledge and skills to offer a microbicide upon availability.

Transition from cylindroma to spiradenoma in CYLD-defective tumours is associated with reduced DKK2 expression.

Patients carrying heterozygous germline truncating mutations in the CYLD gene develop multiple primary hair follicle-related tumours. A highly patterned tumour, termed cylindroma, and a highly disorganized tumour, termed spiradenoma, may both develop in the same patient. Furthermore, histological features of both tumour types have been described within the same tumour specimen. We used three-dimensional computer-aided reconstruction of these tumours to demonstrate contiguous growth of cylindromas into spiradenomas, thus suggesting a transition between the two tumour types. To explore factors that may influence cutaneous tumour patterning, genome-wide transcriptomic analysis of 32 CYLD-defective tumours was performed. Overexpression of the Wnt/ß-catenin signalling pathway was observed relative to normal perilesional tissue. Morphometric analysis was used to investigate the relationship between Wnt pathway-related gene expression and tumour organization. This revealed an association between reduced Dickkopf 2 (DKK2-a negative regulator of the Wnt/ß-catenin signalling pathway) expression and loss of tumour patterning. Reduced DKK2 expression was associated with methylation of the DKK2 gene promoter in the majority of tumour samples assayed. RNA interference-mediated silencing of DKK2 expression in cylindroma primary cell cultures caused an increase in colony formation, cell viability, and anchorage-independent growth. Using these data, we propose a model where epigenetic programming may influence tumour patterning in patients with CYLD mutations.

"Sometimes they used to whisper in our ears": health care workers' perceptions of the effects of abortion legalization in Nepal.

BACKGROUND: Unsafe abortion has been a significant cause of maternal morbidity and mortality in Nepal. Since legalization in 2002, more than 1,200 providers have been trained and 487 sites have been certified for the provision of safe abortion services. Little is known about health care workers' views on abortion legalization, such as their perceptions of women seeking abortion and the implications of legalization for abortion-related health care. METHODS: To complement a quantitative study of the health effects of abortion legalization in Nepal, we conducted 35 in-depth interviews with physicians, nurses, counsellors and hospital administrators involved in abortion care and post-abortion complication treatment services at four major government hospitals. Thematic analysis techniques were used to analyze the data. RESULTS: Overall, participants had positive views of abortion legalization - many believed the severity of abortion complications had declined, contributing to lower maternal mortality and morbidity in the country. A number of participants indicated that the proportion of women obtaining abortion services from approved health facilities was increasing; however, others noted an increase in the number of women using unregulated medicines for abortion, contributing to rising complications. Some providers held negative judgments about abortion patients, including their reasons for abortion. Unmarried women were subject to especially strong negative perceptions. A few of the health workers felt that the law change was encouraging unmarried sexual activity and carelessness around pregnancy prevention and abortion, and that repeat abortion was becoming a problem. Many providers believed that although patients were less fearful than before legalization, they remained hesitant to disclose a history of induced abortion for fear of judgment or mistreatment. CONCLUSIONS: Providers were generally positive about the implications of abortion legalization for the country and for women. A focus on family planning and post-abortion counselling may be welcomed by providers concerned about multiple abortions. Some of the negative judgments of women held by providers could be tempered through values-clarification training, so that women are supported and comfortable sharing their abortion history, improving the quality of post-abortion treatment of complications.

Telehealth for Contraceptive Services During the COVID-19 Pandemic: Provider Perspectives.

BACKGROUND: Telehealth use rapidly increased during the COVID-19 pandemic, including for contraceptive care (e.g., counseling and method provision). This study explored providers' experiences with contraceptive care via telehealth. METHODS: We conducted a survey with open-ended responses among contraceptive providers across the United States. The study population included physicians, nurse practitioners, health educators, and other health professionals (n = 546). Data were collected from April 10, 2020, to January 29, 2021. We conducted qualitative content analysis of the open-ended responses. RESULTS: Providers highlighted the benefits of telehealth, including continuing access to contraceptive services and accommodating patients who faced challenges attending in-person contraceptive visits. Providers at school-based health centers reported telehealth allowed them to reach young people while schools were closed. However, many providers noted a lack of patient awareness about the availability of telehealth services and disparities in access to technology. Providers felt there was less personal connection in virtual contraceptive counseling, noted challenges with confidentiality, and expressed concern about the inability to provide the full range of contraceptive methods through telehealth alone. CONCLUSIONS: The pandemic significantly impacted contraceptive health care delivery. Telehealth has sustained access to contraception in important ways, but has been accompanied by various challenges, including technological access and confidentiality. As hybrid models of care evolve, it is important to assess how telehealth can play a role in providing contraceptive care while addressing its barriers.

Concerns About the Cost of Contraception Among Young Women Attending Community College.

INTRODUCTION: Contraceptive use is lower among students attending community college than 4-year college students, which may be due to financial barriers to accessing contraceptives. This study examined insurance coverage, access to free or low-cost birth control, and concerns about contraceptive costs among women in community college. METHODS: We analyzed data from a study conducted at five community colleges in California and Oregon, which have expanded Medicaid coverage of family planning services for low-income individuals. Participants were students aged 18-25 years who self-identified as female, had vaginal sex, and were not pregnant or trying to become pregnant (N = 389). Multivariate analyses were conducted to examine concerns about the cost of contraception among these young women and how cost concerns varied by insurance coverage and access to free or low-cost birth control. RESULTS: Nearly one-half of participants (49%) were concerned about the cost of contraception. In multivariate models, privately insured women had lower odds of being concerned about the cost of birth control than the uninsured (adjusted odds ratio, 0.42; 95% confidence interval, 0.22-0.83), yet women with public insurance had cost concerns similar to those of women without insurance. Women who reported they knew where to get free or low-cost birth control had lower odds of reporting cost concerns (adjusted odds ratio, 0.42; 95% confidence interval, 0.24-0.75), as did the few women enrolled in a state family planning program (adjusted odds ratio, 0.56; 95% confidence interval, 0.32-1.00). CONCLUSIONS: Even in states with publicly funded services for young people, concerns about the affordability of contraception were common among women, particularly the uninsured or publicly insured. Addressing students' cost concerns is an important aspect of ensuring access to contraception during their pursuit of higher education.

Norepinephrine transport-mediated gene expression in noradrenergic neurogenesis.

BACKGROUND: We have identified a differential gene expression profile in neural crest stem cells that is due to deletion of the norepinephrine transporter (NET) gene. NET is the target of psychotropic substances, such as tricyclic antidepressants and the drug of abuse, cocaine. NET mutations have been implicated in depression, anxiety, orthostatic intolerance and attention deficit hyperactivity disorder (ADHD). NET function in adult noradrenergic neurons of the peripheral and central nervous systems is to internalize norepinephrine from the synaptic cleft. By contrast, during embryogenesis norepinephrine (NE) transport promotes differentiation of neural crest stem cells and locus ceruleus progenitors into noradrenergic neurons, whereas NET inhibitors block noradrenergic differentiation. While the structure of NET und the regulation of NET function are well described, little is known about downstream target genes of norepinephrine (NE) transport. RESULTS: We have prepared gene expression profiles of in vitro differentiating wild type and norepinephrine transporter-deficient (NETKO) mouse neural crest cells using long serial analysis of gene expression (LongSAGE). Comparison analyses have identified a number of important differentially expressed genes, including genes relevant to neural crest formation, noradrenergic neuron differentiation and the phenotype of NETKO mice. Examples of differentially expressed genes that affect noradrenergic cell differentiation include genes in the bone morphogenetic protein (BMP) signaling pathway, the Phox2b binding partner Tlx2, the ubiquitin ligase Praja2, and the inhibitor of Notch signaling, Numbl. Differentially expressed genes that are likely to contribute to the NETKO phenotype include dopamine-beta-hydroxylase (Dbh), tyrosine hydroxylase (Th), the peptide transmitter 'cocaine and amphetamine regulated transcript' (Cart), and the serotonin receptor subunit Htr3a. Real-time PCR confirmed differential expression of key genes not only in neural crest cells, but also in the adult superior cervical ganglion and locus ceruleus. In addition to known genes we have identified novel differentially expressed genes and thus provide a valuable database for future studies. CONCLUSION: Loss of NET function during embryonic development in the mouse deregulates signaling pathways that are critically involved in neural crest formation and noradrenergic cell differentiation. The data further suggest deregulation of signaling pathways in the development and/or function of the NET-deficient peripheral, central and enteric nervous systems.

Essential role of stem cell factor signaling in primary sensory neuron development.

Here we show that stem cell factor (SCF) signaling through its receptor, c-kit, is essential for the development of c-kit-expressing small- and medium-diameter primary sensory neurons. We used the W mouse, which is c-kit deficient and has a perinatal lethal phenotype due to a naturally occurring point mutation in the c-kit gene. In c-kit-null newborn mice, 52.5% of substance P immunoreactive and 31.4% of calcitonin gene-related peptide (CGRP) immunoreactive small- and medium-diameter sensory neurons were absent, whereas large-diameter sensory neurons were unaffected. Equivalent deficits occurred during embryogenesis. There was neither a developmental delay nor degeneration of differentiated neurons. We thus conclude that, in the absence of SCF signaling, neural crest-derived progenitors do not differentiate into c-kit-expressing visceral and somatic afferent neurons.

Challenges in translating evidence to practice: the provision of intrauterine contraception.

OBJECTIVE: Intrauterine contraception is used by many women worldwide, however, it is rarely used in the United States. Although available at no cost from the state family planning program for low-income women in California, only 1.3% of female patients obtain intrauterine contraceptives annually. This study assessed knowledge and practice patterns of practitioners regarding intrauterine contraception. METHODS: We conducted a survey among physicians, nurse practitioners, and physician assistants (n=1,246) serving more than 100 contraceptive patients per year in the California State family planning program. The response rate was 65% (N=816). We used multiple logistic regression to measure the association of knowledge with clinical practice among different provider types. RESULTS: Forty percent of providers did not offer intrauterine contraception to contraceptive patients, and 36% infrequently provided counseling, although 92% thought their patients were receptive to learning about the method. Regression analyses showed younger physicians and those trained in residency were more likely to offer insertions. Fewer than half of clinicians considered nulliparous women (46%) and postabortion women (39%) to be appropriate candidates. Evidence-based views of the types of patients who could be safely provided with intrauterine contraception were associated with more counseling and method provision, as well as with knowledge of bleeding patterns for the levonorgestrel-releasing intrauterine system and copper devices. CONCLUSION: Prescribing practices reflected the erroneous belief that intrauterine contraceptives are appropriate only for a restricted set of women. The scientific literature shows intrauterine contraceptives can be used safely by many women, including postabortion patients. Results revealed a need for training on updated insertion guidelines and method-specific side effects, including differences between hormonal and nonhormonal devices. LEVEL OF EVIDENCE: III.

Gestational dating using last menstrual period and bimanual exam for medication abortion in pharmacies and health centers in Nepal.

OBJECTIVE: To evaluate whether conducting a bimanual examination prior to medication abortion (MAB) provision results in meaningful changes in gestational age (GA) assessment after patient-reported last menstrual period (LMP) in Nepal. STUDY DESIGN: Women ages 16-45 (n=660) seeking MAB at twelve participating pharmacies and government health facilities, between October 2014 and September 2015, self-reported LMP. Trained auxiliary nurse midwives assessed GA using a bimanual exam after recording LMP. We compared GA assessments as measured via patient-reported LMP alone versus via LMP plus bimanual exam. RESULTS: Overall, 660 women (326 at pharmacies, 334 at health facilities) presented for MAB, and 95% were able to provide an LMP. Overall agreement between LMP alone and LMP with bimanual exam was 99.3%. If LMP alone had been used without bimanual exam, fewer than one in 200 women would have been given MAB beyond the legal gestational limit. Among the three women who were ≤63 days by LMP but >63 days by bimanual exam, only one would have received MAB beyond 70 days gestation. Fewer than one in 600 women would not have received MAB care when eligible by adding a bimanual exam. CONCLUSION: There was high agreement between LMP alone and LMP plus bimanual exam. Routine bimanual exam may not be essential for safe and effective MAB care for women who are able to report an LMP. Removing the bimanual exam requirement could decrease barriers to provision outside of currently approved clinical settings and allow for expanded abortion access through provision by providers without bimanual exam training or facilities. IMPLICATIONS: Routine bimanual exams may not be essential for safe medication abortion provision by trained clinicians in pharmacies and health facilities in low resource settings like Nepal.

Pharmacy access to medical abortion from trained providers and post-abortion contraception in Nepal.

OBJECTIVE: To examine whether auxiliary nurse-midwife provision of medical abortion in pharmacies was associated with reduced post-abortion contraceptive use in Nepal. METHODS: The present prospective observational study compared contraceptive use among women aged 16-45 years and up to 63 days of pregnancy, who presented at one of six privately-owned pharmacies or six public health facilities in the Chitwan and Jhapa districts of Nepal for medical abortion between October 16, 2014, and September 1, 2015. Participants obtained medical abortions per Nepali protocol and completed a follow-up visit and interview at 14-21 days. Effective contraceptive use was compared between abortion care settings using multivariable mixed effects logistic regression. RESULTS: Of 605 participants, 600 completed follow-up at 14-21 days; 474 (79.0%) were using a contraceptive method, most commonly pills (180 [30.0%]) and injectables (175 [29.2%]), followed by condoms (82 [13.7%]), long-acting reversible methods (33 [5.5%]), and sterilization (4 [0.7%]). Receipt of care from a private pharmacy was not associated with a difference in the use of hormonal or long-acting methods (adjusted odd ratio 0.89, 95% confidence interval 0.60-1.33). CONCLUSION: Medical abortion provision from pharmacies by qualified providers can provide women with necessary induced-abortion care while not compromising longer-term pregnancy prevention.