Documentation of prenatal contraceptive counseling and fulfillment of permanent contraception: a retrospective cohort study.

BACKGROUND: Barriers exist for the provision of surgery for permanent contraception in the postpartum period. Prenatal counseling has been associated with increased rates of fulfillment of desired postpartum contraception in general, although it is unclear if there is impact on permanent contraception specifically. Thus, we aimed to investigate the association between initial timing for prenatal documentation of a contraceptive plan for permanent contraception and fulfillment of postpartum contraception for those receiving counseling. METHODS: This is a planned secondary analysis of a multi-site cohort study of patients with documented desire for permanent contraception at the time of delivery at four hospitals located in Alabama, California, Illinois, and Ohio over a two-year study period. Our primary exposure was initial timing of documented plan for contraception (first, second, or third trimester, or during delivery hospitalization). We used univariate and multivariable logistic regression to analyze fulfillment of permanent contraception before hospital discharge, within 42 days of delivery, and within 365 days of delivery between patients with a documented plan for permanent contraception in the first or second trimester compared to the third trimester. Covariates included insurance status, age, parity, gestational age, mode of delivery, adequacy of prenatal care, race, ethnicity, marital status, and body mass index. RESULTS: Of the 3103 patients with a documented expressed desire for permanent contraception at the time of delivery, 2083 (69.1%) had a documented plan for postpartum permanent contraception prenatally. After adjusting for covariates, patients with initial documented plan for permanent contraception in the first or second trimester had a higher odds of fulfillment by discharge (aOR 1.57, 95% C.I 1.24-2.00), 42 days (aOR 1.51, 95% C.I 1.20-1.91), and 365 days (aOR 1.40, 95% C.I 1.11-1.75), compared to patients who had their first documented plan in the third trimester. CONCLUSIONS: Patients who had a documented prenatal plan for permanent contraception in trimester one and two experienced higher likelihood of permanent contraception fulfillment compared to those with documentation in trimester three. Given the barriers to accessing permanent contraception, it is imperative that comprehensive, patient-centered counseling and documentation regarding future reproductive goals begin early prenatally.

Permanent contraception is a highly desired form of postpartum contraception in the United States, however there are several barriers to accessing it. In this paper, we investigate whether the timing of when a patient has a documented plan for postpartum contraception has an impact on if they achieve postpartum contraception. This is a cohort study from four hospitals in Illinois, Ohio, California, and Alabama for patients with a desire for postpartum permanent contraception documented in their medical record. We specifically investigated the trimester (first, second, or third) where a patient had a plan for permanent contraception first documented. We then used univariate and multivariate models to determine the relationship between the timing of a plan for permanent contraception and if a patient achieved the procedure at three time-points: hospital discharge, 42-days, and 365-days. Our findings showed that of the 3103 patients in our cohort, only 69.1% of them had a documented plan for postpartum contraception at any point before going to the hospital for their delivery admission. We additionally found that patients who had a documented plan for permanent contraception in the first or second trimester had a higher odds of receiving their postpartum contraception procedure compared to people who had their first documented plan in the third trimester. This showed us the importance of earlier counseling regarding contraception for pregnant patients. There are many barriers to accessing postpartum contraception, so having patient focused counseling about future goals around reproductive health early on in pregnancy is critical.

GeriKit: A novel app for comprehensive geriatric assessment.

Given the growth of the older adult population in the United States, there is a greater need for tools to enable students, trainees, and clinicians to master the comprehensive geriatric assessment. Our goal was to develop a mobile phone application (app) to assist in performing this assessment. We performed a market survey of 45 apps that related to geriatrics and health screening. We evaluated for usability, target audience, and instruments used. Deficiencies included: (1) focusing on a single domain; (2) being time-intensive; and (3) having components behind a paywall. We then designed an app that incorporates instruments that are well-validated, available at no cost, and brief in length. GeriKit includes eight domains: cognition, depression, function, strength, medications, falls, and advance care planning. Each instrument requires fewer than 5 minutes, and once it is completed and scored, the user can access relevant educational materials. GeriKit was launched for Apple users in December 2020, and for Android in August 2021. There have been over 3,400 downloads to date. The GeriKit app makes the comprehensive geriatric assessment accessible to a wide audience, improving the ability to for learners to perform geriatric assessments.

Ongoing contraceptive goals of patients who did not achieve desired postpartum permanent contraception prior to hospital discharge.

OBJECTIVE: To evaluate reasons for non-fulfillment and ongoing contraceptive plans of patients who desired but did not receive inpatient postpartum permanent contraception (PC). STUDY DESIGN: Multi-site retrospective cohort study of 1254 patients with unfulfilled inpatient postpartum PC. We analyzed the reason for PC non-fulfillment, documented contraceptive plan, and method prescription or provision at hospital discharge, six-weeks, and one-year postpartum. RESULTS: In our cohort, 44.3% of patients with unfulfilled inpatient PC did not receive any highly- or moderately-effective contraception within one year postpartum. CONCLUSIONS: Removing barriers to PC fulfillment as well as contraceptive counseling that acknowledges these barriers is imperative.

Deep learning to estimate gestational age from fly-to cineloop videos: A novel approach to ultrasound quality control.

OBJECTIVE: Low-cost devices have made obstetric sonography possible in settings where it was previously unfeasible, but ensuring quality and consistency at scale remains a challenge. In the present study, we sought to create a tool to reduce substandard fetal biometry measurement while minimizing care disruption. METHODS: We developed a deep learning artificial intelligence (AI) model to estimate gestational age (GA) in the second and third trimester from fly-to cineloops-brief videos acquired during routine ultrasound biometry-and evaluated its performance in comparison to expert sonographer measurement. We then introduced random error into fetal biometry measurements and analyzed the ability of the AI model to flag grossly inaccurate measurements such as those that might be obtained by a novice. RESULTS: The mean absolute error (MAE) of our model (±standard error) was 3.87 ± 0.07 days, compared to 4.80 ± 0.10 days for expert biometry (difference -0.92 days; 95% CI: -1.10 to -0.76). Based on simulated novice biometry with average absolute error of 7.5%, our model reliably detected cases where novice biometry differed from expert biometry by 10 days or more, with an area under the receiver operating characteristics curve of 0.93 (95% CI: 0.92, 0.95), sensitivity of 81.0% (95% CI: 77.9, 83.8), and specificity of 89.9% (95% CI: 88.1, 91.5). These results held across a range of sensitivity analyses, including where the model was provided suboptimal truncated fly-to cineloops. CONCLUSIONS: Our AI model estimated GA more accurately than expert biometry. Because fly-to cineloop videos can be obtained without any change to sonographer workflow, the model represents a no-cost guardrail that could be incorporated into both low-cost and commercial ultrasound devices to prevent reporting of most gross GA estimation errors.

Long-Acting Reversible Contraception Use after Non-Receipt of Postpartum Permanent Contraception: A Retrospective Analysis.

Objective: To evaluate long-acting reversible contraception (LARC) use versus permanent contraception (PC) use at hospital discharge through 1 year postpartum after an unfulfilled immediate postpartum PC request. Study Design: We present a secondary analysis of a retrospective cohort study of patients across four study sites between 2018 and 2019 with PC as their documented inpatient postpartum contraceptive plan. We abstracted demographic and clinical characteristics, contraceptive plans and time to contraceptive fulfillment, reasons for non-fulfillment, and pregnancy incidence up to 1 year postpartum from medical records. Results: Of 3,013 patients initially desiring PC, 1,759 patients (58.4%) received PC and 136 patients (4.5%) received LARC on discharge; with an additional 217 patients receiving PC and an additional 176 patients receiving LARC in the 1 year postpartum. Participants who received inpatient LARC were more likely to be younger, to be unmarried, to have Medicaid insurance, and to have delivered vaginally compared with participants who received inpatient PC. Of the 304 patients who received LARC rather than PC during the year postpartum, 49 (16.1%) expressed an interest in LARC prenatally. Reasons for non-fulfillment of PC were varied at different time points postpartum, with 50.3% stating they did not receive PC by 1 year postpartum because they had changed their mind. Conclusions: Ten percent of patients with an unmet postpartum PC request use LARC methods instead at 1 year postpartum. Patients who do use LARC are unlikely to bridge to receipt of PC. Institutions should prioritize fulfillment of desired postpartum PC prior to hospital discharge.