Long-acting reversible contraceptive utilization after policy change increasing device reimbursement to wholesale acquisition cost in Louisiana.

BACKGROUND: Unintended pregnancies, occurring in nearly 1 out of every 2 (45%) pregnancies in the United States, are associated with adverse health and social outcomes for the infant and the mother. The risk of unintended pregnancies is significantly reduced when women use long-acting reversible contraceptives, namely intrauterine devices and implants. Inadequate reimbursement for long-acting reversible contraceptive devices may be an access barrier to long-acting reversible contraceptive uptake. In 2014, the Louisiana Department of Health Bureau of Health Services Financing implemented a policy change that increased the Medicaid reimbursement rates for acquiring long-acting reversible contraceptive devices to the wholesale acquisition cost. OBJECTIVE: To examine the association of a Medicaid policy change that increased the long-acting reversible contraceptive device reimbursement rate to the wholesale acquisition cost (ie, price set by the manufacturers) on long-acting reversible contraceptive uptake among women at risk for unintended pregnancy. MATERIALS AND METHODS: This retrospective, repeated cross-sectional study used 2013-2015 Louisiana Medicaid claims data and contraceptive provision measures to assess associations between patient (age, race, urban/rural residence, postpartum status) and provider (urban/rural location, specialty) characteristics and long-acting reversible contraceptive uptake among contraceptive users (N = 193,623) using bivariate and logistic regression analyses. RESULTS: After long-acting reversible contraceptive reimbursement increased, there was a 2-fold likelihood increase in use in 2015 vs 2013 (odds ratio, 2.08; 95% confidence interval, 1.69-2.55). Long-acting reversible contraceptive uptake was more likely across all patient and provider subgroups in 2015 vs 2013 but notably among patients receiving contraceptive care from family planning clinics (odds ratio, 3.93; 95% confidence interval, 2.34-6.62). CONCLUSION: Removal of a provider-level financial barrier to long-acting reversible contraceptive provision was associated with increased long-acting reversible contraceptive uptake among women at risk for unintended pregnancy. Efforts to improve long-acting reversible contraceptive access should focus on equitable healthcare reimbursement for healthcare providers of reproductive-aged women.

Good practices for the design, analysis, and interpretation of observational studies on birth spacing and perinatal health outcomes.

BACKGROUND: Meta-analyses of observational studies have shown that women with a shorter interpregnancy interval (the time from delivery to start of a subsequent pregnancy) are more likely to experience adverse pregnancy outcomes, such as preterm delivery or small for gestational age birth, than women who space their births further apart. However, the studies used to inform these estimates have methodological shortcomings. METHODS: In this commentary, we summarise the discussions of an expert workgroup describing good practices for the design, analysis, and interpretation of observational studies of interpregnancy interval and adverse perinatal health outcomes. RESULTS: We argue that inferences drawn from research in this field will be improved by careful attention to elements such as: (a) refining the research question to clarify whether the goal is to estimate a causal effect vs describe patterns of association; (b) using directed acyclic graphs to represent potential causal networks and guide the analytic plan of studies seeking to estimate causal effects; (c) assessing how miscarriages and pregnancy terminations may have influenced interpregnancy interval classifications; (d) specifying how key factors such as previous pregnancy loss, pregnancy intention, and maternal socio-economic position will be considered; and (e) examining if the association between interpregnancy interval and perinatal outcome differs by factors such as maternal age. CONCLUSION: This commentary outlines the discussions of this recent expert workgroup, and describes several suggested principles for study design and analysis that could mitigate many potential sources of bias.

Report of the Office of Population Affairs' expert work group meeting on short birth spacing and adverse pregnancy outcomes: Methodological quality of existing studies and future directions for research.

BACKGROUND: The World Health Organization (WHO) recommends that women wait at least 24 months after a livebirth before attempting a subsequent pregnancy to reduce the risk of adverse maternal, perinatal, and infant health outcomes. However, the applicability of the WHO recommendations for women in the United States is unclear, as breast feeding, nutrition, maternal age at first birth, and total fertility rate differs substantially between the United States and the low- and middle-resource countries upon which most of the evidence is based. METHODS: To inform guideline development for birth spacing specific to women in the United States, the Office of Population Affairs (OPA) convened an expert work group meeting in Washington, DC, on 14-15 September 2017 among reproductive, perinatal, paediatric, social, and public health epidemiologists; obstetrician-gynaecologists; biostatisticians; and experts in evidence synthesis related to women's health. RESULTS: Presentations and discussion topics included the methodological quality of existing studies, evaluation of the evidence for causal effects of short interpregnancy intervals on adverse perinatal and maternal health outcomes, good practices for future research, and identification of research gaps and priorities for future work. CONCLUSIONS: This report provides an overview of the presentations, discussions, and conclusions from the expert work group meeting.

Common and Rare Variants Genetic Association Analysis of Cigarettes per Day Among Ever-Smokers in Chronic Obstructive Pulmonary Disease Cases and Controls.

INTRODUCTION: Cigarette smoking is a major environmental risk factor for many diseases, including chronic obstructive pulmonary disease (COPD). There are shared genetic influences on cigarette smoking and COPD. Genetic risk factors for cigarette smoking in cohorts enriched for COPD are largely unknown. METHODS: We performed genome-wide association analyses for average cigarettes per day (CPD) across the Genetic Epidemiology of COPD (COPDGene) non-Hispanic white (NHW) (n = 6659) and African American (AA) (n = 3260), GenKOLS (the Genetics of Chronic Obstructive Lung Disease) (n = 1671), and ECLIPSE (the Evaluation of COPD Longitudinally to Identify Predictive Surrogate Endpoints) (n = 1942) cohorts. In addition, we performed exome array association analyses across the COPDGene NHW and AA cohorts. We considered analyses across the entire cohort and stratified by COPD case-control status. RESULTS: We identified genome-wide significant associations for CPD on chromosome 15q25 across all cohorts (lowest p = 1.78 × 10-15), except in the COPDGene AA cohort alone. Previously reported associations on chromosome 19 had suggestive and directionally consistent associations (RAB4, p = 1.95 × 10-6; CYP2A7, p = 7.50 × 10-5; CYP2B6, p = 4.04 × 10-4). When we stratified by COPD case-control status, single nucleotide polymorphisms on chromosome 15q25 were nominally associated with both NHW COPD cases (ß = 0.11, p = 5.58 × 10-4) and controls (ß = 0.12, p = 3.86 × 10-5) For the gene-based exome array association analysis of rare variants, there were no exome-wide significant associations. For these previously replicated associations, the most significant results were among COPDGene NHW subjects for CYP2A7 (p = 5.2 × 10-4). CONCLUSIONS: In a large genome-wide association study of both common variants and a gene-based association of rare coding variants in ever-smokers, we found genome-wide significant associations on chromosome 15q25 with CPD for common variants, but not for rare coding variants. These results were directionally consistent among COPD cases and controls. IMPLICATIONS: We examined both common and rare coding variants associated with CPD in a large population of heavy smokers with and without COPD of NHW and AA descent. We replicated genome-wide significant associations on chromosome 15q25 with CPD for common variants among NHW subjects, but not for rare variants. We demonstrated for the first time that common variants on chromosome 15q25 associated with CPD are similar among COPD cases and controls. Previously reported associations on chromosome 19 showed suggestive and directionally consistent associations among common variants (RAB4, CYP2A7, and CYP2B6) and for rare variants (CYP2A7) among COPDGene NHW subjects. Although the genetic effect sizes for these single nucleotide polymorphisms on chromosome 15q25 are modest, we show that this creates a substantial smoking burden over the lifetime of a smoker.

Policy change is not enough: engaging provider champions on immediate postpartum contraception.

Rates of short-interval pregnancies that result in unintended pregnancies remain high in the United States and contribute to adverse reproductive health outcomes. Long-acting reversible contraception methods have annual failure rates of <1%, compared with 9% for oral contraceptive pills, and are an effective strategy to reduce unintended pregnancies. To increase access to long-acting reversible contraception in the immediate postpartum period, several State Medicaid programs, which include those in Iowa and Louisiana, recently established reimbursement policies to remove the barriers to reimbursement of immediate postpartum long-acting reversible contraception insertion. We used a mixed-methods approach to analyze 2013-2015 linked Medicaid and vital records data from both Iowa and Louisiana and to describe trends in immediate postpartum long-acting reversible contraception provision 1 year before and after the Medicaid reimbursement policy change. We also used data from key informant interviews with state program staff to understand how provider champions affected policy uptake. We found that the monthly average for the number of insertions in Iowa increased from 4.6 per month before the policy to 6.6 per month after the policy; in Louisiana, the average number of insertions increased from 2.6 per month before the policy to 45.2 per month. In both states, the majority of insertions occurred at 1 academic/teaching hospital. In Louisiana, the additional increase may be due to the engagement of a provider champion who worked at both the state and facility level. Recruiting, training, engaging, and supporting provider champions, as facilitators, with influence at state and facility levels, is an important component of a multipart strategy for increasing successful implementation of state-level Medicaid payment reform policies that allow reimbursement for immediate postpartum long-acting reversible contraception insertions.

Evaluating Iowa Severe Maternal Morbidity Trends and Maternal Risk Factors: 2009-2014.

Objectives To describe statewide SMM trends in Iowa from 2009 to 2014 and identify maternal characteristics associated with SMM, overall and by age group. Methods We used 2009-2014 linked Iowa birth certificate and hospital discharge data to calculate SMM based on a 25-condition definition and 24-condition definition. The 24-condition definition parallels the 25-condition definition, but excludes blood transfusions. We calculated SMM rates for all delivery hospitalizations (N = 196,788) using ICD-9-CM diagnosis and procedure codes. We used log-binomial regression to assess the association of SMM with maternal characteristics, overall and stratified by age groupings. Results In contrast to national rates, Iowa's 25-condition SMM rate decreased from 2009 to 2014. Based on the 25-condition definition, SMM rates were significantly higher among women <20 years and >34 years compared to women 25-34 years. Blood transfusion was the most prevalent indicator, with hysterectomy and disseminated intravascular coagulation (DIC) among the top five conditions. Based on the 24-condition definition, younger women had the lowest SMM rates and older women had the highest SMM rates. SMM rates were also significantly higher among racial/ethnic minorities compared to non-Hispanic white women. Payer was the only risk factor differentially associated with SMM across age groups. First trimester prenatal care initiation was protective for SMM in all models. Conclusions High rates of blood transfusion, hysterectomy, and DIC indicate a need to focus on reducing hemorrhage in Iowa. Both younger and older women and racial/ethnic minorities are identified as high risk groups for SMM that may benefit from special consideration and focus.

Sugar intake is associated with progression from islet autoimmunity to type 1 diabetes: the Diabetes Autoimmunity Study in the Young.

AIMS/HYPOTHESIS: Dietary sugar intake may increase insulin production, stress the beta cells and increase the risk for islet autoimmunity (IA) and subsequent type 1 diabetes. METHODS: Since 1993, the Diabetes Autoimmunity Study in the Young (DAISY) has followed children at increased genetic risk for type 1 diabetes for the development of IA (autoantibodies to insulin, GAD or protein tyrosine phosphatase-like protein [IA2] twice or more in succession) and progression to type 1 diabetes. Information on intake of fructose, sucrose, total sugars, sugar-sweetened beverages, beverages with non-nutritive sweetener and juice was collected prospectively throughout childhood via food frequency questionnaires (FFQs). We examined diet records for 1,893 children (mean age at last follow-up 10.2 years); 142 developed IA and 42 progressed to type 1 diabetes. HLA genotype was dichotomised as high risk (HLA-DR3/4,DQB1*0302) or not. All Cox regression models were adjusted for total energy, FFQ type, type 1 diabetes family history, HLA genotype and ethnicity. RESULTS: In children with IA, progression to type 1 diabetes was significantly associated with intake of total sugars (HR 1.75, 95% CI 1.07-2.85). Progression to type 1 diabetes was also associated with increased intake of sugar-sweetened beverages in those with the high-risk HLA genotype (HR 1.84, 95% CI 1.25-2.71), but not in children without it (interaction p value = 0.02). No sugar variables were associated with IA risk. CONCLUSIONS/INTERPRETATION: Sugar intake may exacerbate the later stage of type 1 diabetes development; sugar-sweetened beverages may be especially detrimental to children with the highest genetic risk of developing type 1 diabetes.

Timing of solid food introduction is associated with urinary F2-isoprostane concentrations in childhood.

BACKGROUND: Timing of solid food introduction in infancy has been associated with several chronic diseases. To explore potential mechanisms, we investigated the relationship between timing of solid food introduction and F2-isoprostanes-a marker of oxidative stress. METHODS: Urinary F2-isoprostanes were assessed in 336 healthy children aged less than 11.5 y with 1,266 clinic visits (mean = 3.8 visits per child) in the Diabetes Autoimmunity Study in the Young. We analyzed the association between F2-isoprostane concentrations and infant diet exposures using linear mixed models adjusted for age, age(2), HLA-DR3/4,DQB1*0302 genotype, first-degree relative with type 1 diabetes, maternal age, maternal education, sex, and exposure to in utero cigarette smoke. RESULTS: Later solid food introduction was associated with lower F2-isoprostane concentrations in childhood (on average, 0.10 ng/mg per month of age at introduction; estimate: -0.10 (95% confidence interval (CI): -0.18, -0.02) P value = 0.02). Moreover, childhood F2-isoprostane concentrations were, on average, 0.24 ng/mg lower in individuals breastfed at solid food introduction (estimate: -0.24 (95% CI: -0.47, -0.01) P value = 0.04) compared with those who were not. Associations remained significant after limiting analyses to F2-isoprostanes after 2 y of age. CONCLUSION: Our results suggest a long-term protective effect of later solid food introduction and breastfeeding at solid food introduction against increased F2-isoprostane concentrations throughout childhood.

The effect of childhood cow's milk intake and HLA-DR genotype on risk of islet autoimmunity and type 1 diabetes: the Diabetes Autoimmunity Study in the Young.

BACKGROUND: Cow's milk intake has been inconsistently associated with islet autoimmunity (IA) and type 1 diabetes (T1D) development. Genetic and environmental factors may modify the effect of cow's milk on IA and T1D risk. METHODS: The Diabetes Autoimmunity Study in the Young (DAISY) follows children at increased T1D risk of IA (presence of autoantibodies to insulin, GAD65, or IA-2 twice in succession) and T1D development. We examined 1835 DAISY children with data on cow's milk intake: 143 developed IA, 40 subsequently developed T1D. Cow's milk protein and lactose intake were calculated from prospectively collected parent- and self-reported food frequency questionnaires (FFQ). High risk HLA-DR genotype: HLA-DR3/4,DQB1*0302; low/moderate risk: all other genotypes. We examined interactions between cow's milk intake, age at cow's milk introduction, and HLA-DR genotype in IA and T1D development. Interaction models contained the base terms (e.g., cow's milk protein and HLA-DR genotype) and an interaction term (e.g., cow's milk protein*HLA-DR genotype). RESULTS: In survival models adjusted for total calories, FFQ type, T1D family history, and ethnicity, greater cow's milk protein intake was associated with increased IA risk in children with low/moderate risk HLA-DR genotypes [hazard ratio (HR): 1.41, 95% confidence interval (CI): 1.08-1.84], but not in children with high risk HLA-DR genotypes. Cow's milk protein intake was associated with progression to T1D (HR: 1.59, CI: 1.13-2.25) in children with IA. CONCLUSIONS: Greater cow's milk intake may increase risk of IA and progression to T1D. Early in the T1D disease process, cow's milk intake may be more influential in children with low/moderate genetic T1D risk.

Erythrocyte membrane docosapentaenoic acid levels are associated with islet autoimmunity: the Diabetes Autoimmunity Study in the Young.

AIMS/HYPOTHESES: We previously reported that lower n-3 fatty acid intake and levels in erythrocyte membranes were associated with increased risk of islet autoimmunity (IA) but not progression to type 1 diabetes in children at increased risk for diabetes. We hypothesise that specific n-3 fatty acids and genetic markers contribute synergistically to this increased risk of IA in the Diabetes Autoimmunity Study in the Young (DAISY). METHODS: DAISY is following 2,547 children at increased risk for type 1 diabetes for the development of IA, defined as being positive for glutamic acid decarboxylase (GAD)65, IA-2 or insulin autoantibodies on two consecutive visits. Using a case-cohort design, erythrocyte membrane fatty acids and dietary intake were measured prospectively in 58 IA-positive children and 299 IA-negative children. RESULTS: Lower membrane levels of the n-3 fatty acid, docosapentaenoic acid (DPA), were predictive of IA (HR 0.23; 95% CI 0.09, 0.55), while α-linolenic acid (ALA), eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) were not, adjusting for HLA and diabetes family history. We examined whether the effect of dietary intake of the n-3 fatty acid ALA on IA risk was modified by fatty acid elongation and desaturation genes. Adjusting for HLA, diabetes family history, ethnicity, energy intake and questionnaire type, ALA intake was significantly more protective for IA in the presence of an increasing number of minor alleles at FADS1 rs174556 (pinteraction = 0.017), at FADS2 rs174570 (pinteraction = 0.016) and at FADS2 rs174583 (pinteraction = 0.045). CONCLUSIONS/INTERPRETATION: The putative protective effect of n-3 fatty acids on IA may result from a complex interaction between intake and genetically controlled fatty acid desaturation.

Estimates of use of preferred contraceptive method in the United States: a population-based study.

Background: In the U.S. and globally, dominant metrics of contraceptive access focus on the use of certain contraceptive methods and do not address self-defined need for contraception; therefore, these metrics fail to attend to person-centeredness, a key component of healthcare quality. This study addresses this gap by presenting new data from the U.S. on preferred contraceptive method use, a person-centered contraceptive access indicator. Additionally, we examine the association between key aspects of person-centered healthcare access and preferred contraceptive method use. Methods: We fielded a nationally representative survey in the U.S. in English and Spanish in 2022, surveying non-sterile 15-44-year-olds assigned female sex at birth. Among current and prospective contraceptive users (unweighted n = 2119), we describe preferred method use, reasons for non-use, and differences in preferred method use by sociodemographic characteristics. We conduct logistic regression analyses examining the association between four aspects of person-centered healthcare access and preferred contraceptive method use. Findings: A quarter (25.2%) of current and prospective users reported there was another method they would like to use, with oral contraception and vasectomy most selected. Reasons for non-use of preferred contraception included side effects (28.8%), sex-related reasons (25.1%), logistics/knowledge barriers (18.6%), safety concerns (18.3%), and cost (17.6%). In adjusted logistic regression analyses, respondents who felt they had enough information to choose appropriate contraception (Adjusted Odds Ratio [AOR] 3.31; 95% CI 2.10, 5.21), were very (AOR 9.24; 95% CI 4.29, 19.91) or somewhat confident (AOR 3.78; 95% CI 1.76, 8.12) they could obtain desired contraception, had received person-centered contraceptive counseling (AOR 1.72; 95% CI 1.33, 2.23), and had not experienced discrimination in family planning settings (AOR 1.58; 95% CI 1.13, 2.20) had increased odds of preferred contraceptive method use. Interpretation: An estimated 8.1 million individuals in the U.S. are not using a preferred contraceptive method. Interventions should focus on holistic, person-centered contraceptive access, given the implications of information, self-efficacy, and discriminatory care for preferred method use. Funding: Arnold Ventures.

Evidence of stage- and age-related heterogeneity of non-HLA SNPs and risk of islet autoimmunity and type 1 diabetes: the diabetes autoimmunity study in the young.

Previously, we examined 20 non-HLA SNPs for association with islet autoimmunity (IA) and/or progression to type 1 diabetes (T1D). Our objective was to investigate fourteen additional non-HLA T1D candidate SNPs for stage- and age-related heterogeneity in the etiology of T1D. Of 1634 non-Hispanic white DAISY children genotyped, 132 developed IA (positive for GAD, insulin, or IA-2 autoantibodies at two or more consecutive visits); 50 IA positive children progressed to T1D. Cox regression was used to analyze risk of IA and progression to T1D in IA positive children. Restricted cubic splines were used to model SNPs when there was evidence that risk was not constant with age. C1QTNF6 (rs229541) predicted increased IA risk (HR: 1.57, CI: 1.20-2.05) but not progression to T1D (HR: 1.13, CI: 0.75-1.71). SNP (rs10517086) appears to exhibit an age-related effect on risk of IA, with increased risk before age 2 years (age 2 HR: 1.67, CI: 1.08-2.56) but not older ages (age 4 HR: 0.84, CI: 0.43-1.62). C1QTNF6 (rs229541), SNP (rs10517086), and UBASH3A (rs3788013) were associated with development of T1D. This prospective investigation of non-HLA T1D candidate loci shows that some SNPs may exhibit stage- and age-related heterogeneity in the etiology of T1D.

The status of person-centered contraceptive care in the United States: Results from a nationally representative sample.

CONTEXT: The Person-Centered Contraceptive Care measure (PCCC) evaluates patient experience of contraceptive counseling, a construct not represented within United States surveillance metrics of contraceptive care. We explore use of PCCC in a national probability sample and examine predictors of person-centered contraceptive care. METHODS: Among 2228 women from the 2017-2019 National Survey of Family Growth who reported receiving contraceptive care in the last year, we conducted univariate and multivariable linear regression to identify associations between individual characteristics and PCCC scores. RESULTS: PCCC scores were high ( x ¯ : 17.84, CI: 17.59-18.08 on a 4-20 scale), yet varied across characteristics. In adjusted analyses, Hispanic identity with Spanish language primacy and non-Hispanic other or multiple racial identities were significantly associated with lower average PCCC scores compared to those of non-Hispanic white identity (B = -1.232 [-1.970, -0.493]; B = -0.792 [-1.411, -0.173]). Gay, lesbian, or bisexual identity was associated with lower average PCCC scores compared to heterosexual (B = -0.673 [-1.243, -0.103]). PCCC scores had a positive association with incomes of 150%-299% and ≥300% of the federal poverty level compared to those of income <150% (150%-299%: B = 0.669 [0.198, 1.141]; ≥300%: B = 0.892 [0.412, 1.372]). Cannabis use in the past year was associated with lower PCCC scores (B = -0.542 [-0.971, -0.113]). CONCLUSIONS: The PCCC can capture differential experiences of contraceptive care to monitor patient experience and to motivate and track care quality over time. Differences in reported quality of care have implications for informing national priorities for contraceptive care improvements.

Screening and Intervention for Psychosocial Needs by U.S. Obstetrician-Gynecologists.

Objectives: To determine the psychosocial needs screening and intervention practices of obstetrician-gynecologists (OBGYNs) and elucidate characteristics associated with screening and resource availability. Methods: We administered a cross-sectional paper and online survey to 6288 U.S. office-based OBGYNs from March 18 to September 1, 2020, inquiring about screening and intervention practices for intimate partner violence, depression, housing, and transportation. We analyzed associations between demographic/practice characteristics and screening/having resources for all four needs. Results: 1210 OBGYNs completed the survey. One hundred ninety-five OBGYNs (16%) reported their practices screened all patients for all four needs. Having resources to address all four needs (prevalence ratio [PR] = 4.39, 95% confidence interval [CI] = 3.04-6.34), working in health centers/clinics (PR = 2.22, 95% CI = 1.43-3.45), and seeing ≥50% Medicaid patients (PR = 1.62, 95% CI = 1.02-2.58) were associated with screening for all four needs. One hundred sixty-eight OBGYNs (14%) reported their practices had resources onsite to address all four needs. Working in health centers/clinics (PR = 3.99, 95% CI = 2.56-6.22), large practices (PR = 3.37, 95% CI = 1.63-6.95), Medicaid expansion states (PR = 2.60, 95% CI = 1.45-4.65), and practices with >11% uninsured patients (PR 2.30, 95% CI = 1.31-4.04) were associated with having resources onsite for all four needs. Conclusion: Most OBGYN practices appeared underresourced to address psychosocial needs within clinical care. Innovative financial models or collaborative care models may help incentivize this work.

Required examinations and tests before initiating contraception: Provider practices from a national cross-sectional survey.

OBJECTIVE(S): We estimated the prevalence of requiring specific examinations or tests before providing contraception in a nationwide survey of family planning providers. STUDY DESIGN: We conducted a cross-sectional survey of public-sector health centers and office-based physicians providing family planning services across the United States in 2019 (n = 1395). We estimated the weighted proportion of providers (or their health center or practice) who required blood pressure measurement, pelvic examination (bimanual examination and cervical inspection), Papanicolaou (Pap) smear, clinical breast examination (CBE), and chlamydia and gonorrhea (CT/GC) screening before initiating hormonal or intrauterine contraception (IUC) for healthy women. We performed multivariable regression to identify factors associated with pelvic examination practices aligned with clinical recommendations; these recommendations classify examinations and tests as recommended or unnecessary before initiation of specific contraceptive methods. RESULTS: The overall response rate was 51%. Most providers required blood pressure measurement before initiating each method. Unnecessary CBE, Pap smears, and CT/GC screening were required by 14% to 33% of providers across methods. Fifty-two to 62% of providers required recommended pelvic examination before IUC placement; however, 16% to 23% of providers required unnecessary pelvic examinations before non-intrauterine hormonal method initiation. Factors associated with recommendation-aligned pelvic examination practices included having a higher proportion of patients using public funding (Medicaid or other assistance) and more recently completing formal clinical training. CONCLUSIONS: Almost half (47%) of providers did not require necessary pelvic examination before placing IUC. Conversely, many providers required unnecessary examinations and tests before contraception initiation for patients. IMPLICATIONS: Most providers required the few recommended examinations and tests for safe contraceptive provision. Reduction of unnecessary examinations and tests may reduce barriers to contraceptive access. There are also opportunities to increase use of recommended examinations, as up to 48% of providers did not require recommended pelvic examination before IUC.

Understanding the extent of contraceptive non-use among women at risk of unintended pregnancy, National Survey of Family Growth 2011-2017.

OBJECTIVE: To describe characteristics of U.S. contraceptive non-users to inform tailored contraceptive access initiatives. STUDY DESIGN: We used National Survey of Family Growth data from 2011 to 2017 to identify characteristics of contraceptive non-users compared to other women ages 15-44 at risk for unintended pregnancy. We also examined reasons for not using contraception by when non-users expected their next birth. We calculated unadjusted and adjusted prevalence ratios using two definitions of contraceptive non-use: (1) contraceptive non-use during the interview month, and (2) a more refined definition based on contraception use during the most recent month of sexual intercourse and expectation of timing of next birth. We considered p-values < 0.05 statistically significant. RESULTS: Approximately 20% (n = 2844) of 12,071 women at risk of unintended pregnancy were classified as standard contraceptive non-users. After adjusting for all other variables, non-users were more likely to be low-income, uninsured, never married, expect a birth within 2 years, and have zero or one parity. The top reasons for contraceptive non-use were not minding if they got pregnant (22.6%), worried about contraceptive side effects (21.0%), and not thinking they could get pregnant (17.6%). After applying the more refined non-user definition, we identified 5.7% (n = 721) of women as non-users; expecting a birth within 2-5 years and having a parity of one were associated with non-use after adjustment of all other factors. CONCLUSION: Our more refined definition of non-users could be used in future studies examining the causes of unintended pregnancy and to inform programmatic interventions to reduce unintended pregnancy. IMPLICATIONS: Describing contraceptive non-users and reasons for contraceptive non-use could help us better understand reasons for unintended pregnancy and inform tailored contraceptive access initiatives.

Out-of-pocket spending for oral contraceptives among women with private insurance coverage after the Affordable Care Act.

OBJECTIVES: We aimed to identify which types and brands of oral contraceptive pills have the largest shares of oral contraceptive users in large employer plans with out-of-pocket spending and which oral contraceptives have the highest average annual out-of-pocket costs. STUDY DESIGN: We analyzed a sample of medical claims obtained from the 2003-2018 IBM MarketScan Commercial Claims and Encounters Database (MarketScan), which is a database with claims information provided by large employer plans. We only included claims for women between the ages of 15 and 44 years who were enrolled in a plan for more than half a year as covered workers or dependents. To calculate out-of-pocket spending, we summed copayments, coinsurance and deductibles for the oral contraceptive prescriptions. RESULTS: We found that 10% of oral contraceptive users in large employer plans still had out-of-pocket costs in 2018. Oral contraceptives with the largest share of users with annual out-of-pocket spending are brand-name contraceptives with generic alternatives. The three contraceptives with the highest average annual out-of-pocket spending were brand-name contraceptives without generic alternatives. Three of the 10 contraceptives with the largest shares of users who have annual out-of-pocket spending and 3 of the 10 contraceptives with the highest average annual out-of-pocket spending contain iron. CONCLUSIONS: Women with health insurance are still paying out of pocket for oral contraception, and future research should investigate which health plans have fewer fully covered contraceptives and effective modes of educating providers and patients about how to maximize the no-cost coverage benefit that has been extended to women. IMPLICATIONS: The Affordable Care Act eliminated out-of-pockets costs for contraception for most insured women. However, some women still pay out of pocket for certain oral contraceptive brands and types that may have covered alternatives. Providers and patients could benefit from more education on how to maximize the no-cost coverage benefit extended to women.

Lessons Learned in Creating Interoperable Fast Healthcare Interoperability Resources Profiles for Large-Scale Public Health Programs.

OBJECTIVE: This article describes lessons learned from the collaborative creation of logical models and standard Health Level Seven (HL7) Fast Healthcare Interoperability Resources (FHIR) profiles for family planning and reproductive health. The National Health Service delivery program will use the FHIR profiles to improve federal reporting, program monitoring, and quality improvement efforts. MATERIALS AND METHODS: Organizational frameworks, work processes, and artifact testing to create FHIR profiles are described. RESULTS: Logical models and FHIR profiles for the Family Planning Annual Report 2.0 dataset have been created and validated. DISCUSSION: Using clinical element models and FHIR to meet the needs of a real-world use case has been accomplished but has also demonstrated the need for additional tooling, terminology services, and application sandbox development. CONCLUSION: FHIR profiles may reduce the administrative burden for the reporting of federally mandated program data.

Patterns and trends in contraceptive use among women attending Title X clinics and a national sample of low-income women.

OBJECTIVES: To describe the types of contraception used by women attending Title X-funded clinics and a comparable group of low-income reproductive-age women at risk of unintended pregnancy. STUDY DESIGN: We estimated the percentage of reproductive aged (15-44 years) women using contraception, by method type and level of effectiveness in preventing pregnancy (i.e., most, moderately, and less effective), using Title X Family Planning Annual Report (2006-2016) and National Survey of Family Growth (2006-2015) data. We divided most effective methods into permanent (female and male sterilization) and reversible (long-acting reversible contraceptives [LARCs]) methods. RESULTS: Among Title X clients during 2006-2016, use of LARCs increased (3-14%); use of moderately effective methods decreased (64-54%); and use of sterilization (~ 2%), less effective methods (21-20%), and no method (8-7%) was unchanged. These same trends in contraceptive use were observed in a comparable group of women nationally during 2006-2015, during which LARC use increased (5-19%, p < .001); moderately effective method use decreased (60-48%, p < .001); and use of sterilization (~5%), less effective methods (19%), and no method (11-10%) was unchanged. CONCLUSIONS: The contraceptive method mix among Title X clients differs from that of low-income women at risk of unintended pregnancy nationally, but general patterns and trends are similar in the two populations. Research is needed to understand whether method use patterns among low-income women reflect their preferences, access, or the conditions of the supply environment. IMPLICATIONS: This study contributes to our understanding of patterns and trends in contraceptive use among two groups of reproductive-age women - Title X clients and low-income women nationally who are at risk of unintended pregnancy. The findings highlight areas for further research.

Contraceptive Counseling in Clinical Settings: An Updated Systematic Review.

CONTEXT: The objective of this systematic review was to update a prior review and summarize the evidence (newly identified and cumulative) on the impact of contraceptive counseling provided in clinical settings. EVIDENCE ACQUISITION: Multiple databases, including PubMed, were searched during 2016-2017 for articles published from March 1, 2011, to November 30, 2016. EVIDENCE SYNTHESIS: The search strategy identified 24,953 articles; ten studies met inclusion criteria. Two of three new studies that examined contraceptive counseling interventions (i.e., enhanced models to standard of care) among adolescents and young adults found a statistically significant positive impact on at least one outcome of interest. Five of seven new studies that examined contraceptive counseling, in general, or specific counseling interventions or aspects of counseling (e.g., personalization) among adults or mixed populations (adults and adolescents) found a statistically significant positive impact on at least one outcome of interest. In combination with the initial review, six of nine studies among adolescents and young adults and 16 of 23 studies among adults or mixed populations found a statistically significant positive impact of counseling on at least one outcome of interest. CONCLUSIONS: Overall, evidence supports the utility of contraceptive counseling, in general, and specific interventions or aspects of counseling. Promising components of contraceptive counseling were identified. The following would strengthen the evidence base: improved documentation of counseling content and processes, increased attention to the relationships between client experiences and behavioral outcomes, and examining the comparative effectiveness of different counseling approaches to identify those that are most effective. THEME INFORMATION: This article is part of a theme issue entitled Updating the Systematic Reviews Used to Develop the U.S. Recommendations for Providing Quality Family Planning Services, which is sponsored by the Office of Population Affairs, U.S. Department of Health and Human Services.