Intrauterine Device Placement Success for Adolescents and Young Adults at Community-Based Reproductive Health Clinics.

BACKGROUND: Despite the endorsement of intrauterine device (IUD) use in adolescents and young adults (AYAs) by leading professional organizations and demonstrated acceptance and desirability by AYAs, clinicians may worry about the procedural difficulty of IUD device placement in younger patients. OBJECTIVE: The aim of this study was to evaluate the clinical outcomes of first-attempt IUD placement in an AYA population by vaginal delivery (VD) history. STUDY DESIGN: We performed a retrospective cohort study of patients under 25 years old at reproductive health clinics with an IUD placement attempt between January 1 and August 31, 2017. We abstracted sociodemographic characteristics, pregnancy history, and procedural characteristics including complications. Bivariate analyses compared successful first-attempt IUD placement by VD history. We also assessed the frequency of secondary clinical outcomes including ancillary measures used, provider type, symptoms reported during the procedure, and complications. RESULTS: We included 1325 participants (median age = 21.3 years), including 42 (3.2%) with a previous VD. Nearly all IUD placements were successful on the first attempt (n = 1301, 98.2%) and performed by advanced practice clinicians (n = 1314, 99.2%). First-attempt IUD placement success was similar in those participants with and without VD (P > .999). Ancillary measures other than nonsteroidal anti-inflammatory drugs were used infrequently (n = 16, 3.6%). Among participants with an unsuccessful placement, 66.7% returned, and all had a successful IUD placement on the second attempt. Documented complications within 6 months of placement were rare (n = 29) and mostly comprised expulsions (n = 27, 93.1%). CONCLUSION: IUD placement success among AYAs at community-based reproductive health clinics is high and is not associated with a history of VD.

Willingness to use novel reversible methods of male birth control: a community-based survey of cisgender men in the United States.

BACKGROUND: There is high global demand for new methods of male birth control (MBC). However, contemporary evidence regarding men's method-specific attitudes and their determinants is sparse. METHODS: Non-sterilized cisgender men ages 18-45 with recent history of female sex partners were surveyed at a large community event in the Midwestern US. We examined variation in participants' willingness to use MBC by method (gel, pill, injection, implant, and vas occlusion), potential side effects, and potential barriers. We estimated crude and adjusted prevalence ratios (aPRs) for associations between participant characteristics and willingness to use ≥ 1 MBC method. RESULTS: Overall, 72% of participants (n = 187; mean age, 29) were very willing to use ≥ 1 MBC method although support for individual methods ranged widely from 62% (pill) to 24% (vas occlusion). In bivariate analysis of sociodemographic and health characteristics, few demonstrated associations with MBC willingness. In a multivariable model, willingness was independently related to age (30-39 vs. 18-29 years old, aPR = 1.24, 95% CI 1.04-1.48) and having ever been tested for HIV (aPR = 1.27, 95% CI 1.07-1.51). Willingness to tolerate side effects was < 10% for most items. The most commonly endorsed barriers to MBC use were high cost (77%) and side effects (66%). CONCLUSIONS: Enthusiasm for MBC was high but waned in the context of potential side effects and barriers. Additional research on MBC attitudes in socioeconomically and culturally diverse populations worldwide is sorely needed.

Prevalence of hypertensive disorders of pregnancy at or beyond 39 weeks gestational age and associated maternal complications.

OBJECTIVE: Estimate the prevalence of hypertensive disorder of pregnancy (HDP) at term, define population characteristics, and calculate adverse maternal outcomes. METHODS: Retrospective study. RESULTS: We included 4,702,468 pregnancies. HDP increased linearly from 4.5% (2014) to 6.0% (2018). HDP was more frequent among black (PR 1.19), obese (PR 2.31 to 3.70), with gestational (PR 1.87) or pregestational diabetes (PR 2.16). Increased transfusion (PR 2.52), intensive care unit admission (PR 3.38), and unplanned hysterectomy (PR 1.78) with HDP. CONCLUSION: Our study quantifies the increased risks for maternal and neonatal complications related to the development of HDP at or beyond 39 weeks among nulliparous women.

Validation of a neurovascular comorbidity index for risk adjustment of comorbid conditions among ischemic stroke patients receiving reperfusion treatment.

OBJECTIVE: To validate a comorbidity index specific to neurovascular patients and determine its performance relative to the Charlson Comorbidity Index (CCI) and Elixhauser Comorbidity Index (ECI) among ischemic stroke patients receiving reperfusion treatments. METHODS: Patients with ischemic stroke were identified in the National Inpatient Sample from Quarter 4 2015 to Quarter 4 2017. Ischemic stroke patients receiving reperfusion treatment, either with intravenous thrombolysis (IVT) only or mechanical thrombectomy (MT), were studied. The accuracy of the neurovascular comorbidities index (NCI) was compared to both the CCI and ECI in predicting in-hospital death and poor outcome (defined as death prior to discharge or discharge to a short-term hospital, a skilled nursing facility, an intermediate care facility, another long-term facility, or home health care). RESULTS: There were 25,147 ischemic stroke patients who received reperfusion therapy with either IVT only or MT (with or without IVT). Approximately 6.9% of patients died during their hospitalization, and 65.4% of patients were classified as having a poor outcome based on their discharge disposition. The NCI outperformed both the CCI and ECI in predicting in-hospital death (IVT only, p<0.0001; MT, p<0.0001) and poor outcomes (IVT only, p<0.0001; MT, p<0.0001). CONCLUSION: The NCI is a more powerful predictor of in-hospital death and poor outcomes when compared to the CCI or ECI among ischemic stroke patients receiving reperfusion therapies. Further validation studies are needed to confirm the accuracy of the NCI among other neurovascular patient populations.

What Do Women Want? Identifying Life Goals in a Community-Based Sample of Women Aged ≥60 Years.

Few studies have examined women's perspectives on their health and priorities in older age. In the current study, we administered a cross-sectional survey to women aged ≥60 years, recruited at a large community event in 2019. Participants (N = 303; mean age = 68 years) reported up to three 12-month life goals in open-text fields (N = 1,053 goals). Our qualitative analysis identified 25 themes under four domains: Health and Wellness (n = 339 goals), Work and Leisure (n = 316 goals), Relationships (n = 199 goals), and Personal Growth (n = 170 goals). The most frequent themes pertained to family relationships, travel, staying healthy, and physical activity. Findings did not vary by participants' comorbidity status. Women have diverse aspirations as they age, including nurturing relationships, acquiring novel skills and experiences, and maintaining overall health and wellness. Gerontological nurses can better meet the needs of this population by expanding their awareness of patients' life goals and partnering with women to optimize health to achieve these goals. [Journal of Gerontological Nursing, 48(12), 25-33.].

Associations Between Income Status and Perceived Barriers to Using Long-Acting Reversible Contraception: An Exploratory Study.

Introduction: Barriers to long-acting reversible contraception (LARC) use in the United States have been described in prior studies, but few have focused on women's income status. We explored associations between income status and perceived LARC barriers in a community-based sample of reproductive-aged women. Methods: Non-pregnant, heterosexually active women aged 18 to 40 years completed a cross-sectional survey at a large community event in the Midwestern U.S. in 2018. Outcome measures were comprised of 26 survey items gauging perceived barriers to LARC use (e.g., access barriers, side effects). We estimated crude and age-adjusted prevalence ratios (PRs) for each outcome by participants' income status: low-income (≤ 200% of federal poverty guideline) versus higher income. Results: Low-income women (n = 72) were significantly more likely than higher income women (n = 183) to endorse 11 of the 26 barriers to LARC use (PR range, 1.23-7.63). Cost of LARC was the most frequently identified access barrier and was more acute for low-income women (PR 1.57, 95% CI 1.17-2.11). After adjustment for age, most associations were attenuated. However, low-income women were still more likely to report concerns about LARC use due to family expectations or beliefs (aPR 3.69, 95% CI 1.15-11.8). Conclusion: Low-income women perceive more barriers to LARC access and more negative perceptions about use. While these associations also correlate with age, they nonetheless reflect concerns that impact contraceptive equity. Efforts to increase LARC access should address these barriers and focus on concerns more common among low-income women regarding LARC use.

Sexual and reproductive health during international travel: Expectations and experiences among female university students.

ObjectiveTo evaluate female students' expectations and experiences related to their sexual and reproductive health (SRH) during international travel. Participants: Female students from a US university with a history of sex with men completed a cross-sectional survey about their upcoming (Pre-travelers; n = 170) or recent (Travelers; n = 340) international travel. Methods: Descriptive statistics were used to characterize pre-travel SRH expectations (for Pre-travelers) and to determine the prevalence of 15 SRH experiences during both recent and lifetime travel (for Travelers). Results: Pre-travelers overwhelmingly expected to be abstinent and many were unsure of whether SRH supplies would be accessible in their destination. During Travelers' recent trip, SRH experiences included getting off schedule with contraception (30%), unwanted sexual touching (18%), new male sex partners (17%), and unexpected sex (15%); lifetime prevalence estimates were higher. Conclusions: International travel poses risks to female students' SRH that can be addressed by pre-travel counseling from study-abroad programs and clinicians.

International Travel as a Context for Sexual and Contraceptive Behaviors: A Qualitative Study of Young Women Traveling Outside the U.S.

International travel is popular worldwide, yet its implications for sexual and reproductive health are not fully understood. Few studies have examined the contextual factors that shape women's sexual and contraceptive behaviors-and thus, their risk of unintended pregnancy and sexually transmitted infections (STIs)-while traveling outside their home country. In this qualitative study, female university students with recent (n = 25) or upcoming (n = 19) travel outside the U.S. completed semi-structured interviews from October 2015 to March 2017. Transcripts were analyzed for themes related to contraceptive and sexual behaviors: (1) participants' pre-travel expectations of sex; (2) the circumstances surrounding sexual encounters with men while traveling; (3) negotiation about condom and contraception use with partners; and (4) factors affecting contraceptive adherence. Participants generally expected to be abstinent during travel, citing myriad rationales that included personal values, no perceived opportunities for sex, and the nature of the trip. Some travelers had unexpected sexual encounters, involving health-protecting behaviors and risk-taking (e.g., unprotected sex, substance use). New sexual partnerships were fueled by increased attention from men, situational disinhibition, and perceived heightened intimacy. International travel brought many contraceptive considerations (adequacy of supplies, access to refrigeration, time zone differences, etc.) as well as obstacles that triggered contraceptive lapses and discontinuation. Pill users described the most challenges, while travelers using intrauterine devices expressed appreciation for their maintenance-free contraception. This study suggests complex associations between international travel and young women's sexual and reproductive health. Some travelers were more vulnerable to situational risk factors, while others may have been more insulated. We identify potential intervention opportunities via clinical services, education, and policy to reduce young women's risk of adverse sexual and reproductive health outcomes while traveling abroad. We urge greater recognition of and conversations about contraceptive lapse and unintended pregnancy as potential health risks for female travelers of reproductive age, just as clinical guidelines acknowledge travel-associated STI.

Pregnancy Prevention on the Fly: An Exploratory Study of Contraceptive Lapse Among Young Women Traveling Internationally.

Background: International travel is increasingly popular, and women comprise half of all outbound travel from the United States (almost 46 million trips in 2017). The implications of international travel for women's reproductive health are not fully clear due to lack of data on travelers' contraceptive use. Methods: Women attending a U.S. university (n = 340) completed a cross-sectional survey in 2016-2017 about their sexual and reproductive health during recent international travel. Participants were 18-29 years old (mean: 21.1) and had a history of male sex partners. We calculated the prevalence of contraceptive lapse-nonadherence (e.g., missed pill) or having sex without contraception-by individual and travel-related characteristics and evaluated multivariable correlates of lapse using modified Poisson regression and prevalence ratios (PRs). Results: Prevalence of contraceptive lapse was 29% overall and especially high among pill users (50%). Multivariable correlates of lapse were the following: using the pill (PR 4.51, 95% confidence interval [CI] 2.57-7.94) compared to other or no contraception; trip duration of >30 days versus 1-7 days (PR 2.02, 95% CI 1.14-3.57); having trouble communicating with a male partner about contraception (PR 1.79, 95% CI 1.16-2.75); a high perceived impact of language barriers (PR 1.77, 95% CI 1.02-3.08); and perceiving local access to abortion as difficult (PR 1.67, 95% CI 1.22-2.27). There was a trend toward increased lapse prevalence among participants who had difficulty maintaining their contraceptive schedule while traveling across time zones (PR 1.38, 95% CI 1.00-1.91). Conclusions: During international travel, prevalence of contraceptive lapse varied by young women's chosen contraceptive method as well as travel-specific factors. Pretravel counseling by clinicians can help women anticipate contraceptive challenges and reduce the likelihood of unintended pregnancy.

Risk of Contraceptive Lapse and New Sexual Partnership Among Female University Students Traveling Internationally.

CONTEXT: International travel is common and may influence women's sexual and reproductive health through myriad pathways. Existing studies focus on travelers' risk of acquiring STDs, but not their pregnancy prevention behaviors. Further, it is unclear whether sexual and reproductive health outcomes observed for female travelers are associated with travel itself, because few studies compare travelers with nontravelers. METHODS: An online survey was conducted in 2016-2017 among females attending a U.S. university who reported a history of sex with men; the sample comprised 340 students who had traveled internationally in the past three months (travelers) and 170 who intended to travel in the next three months (pretravelers). Multivariable modified Poisson regression models assessed associations between travel status and two outcomes during travelers' recent trip or a period of similar duration for pretravelers: contraceptive lapse (incorrect or inconsistent use of any method) and new sexual partnership. RESULTS: Travelers and pretravelers reported similar levels of contraceptive lapse (29% and 32%, respectively) and new sexual partnerships (17% and 12%). Multivariable analysis confirmed that travelers were no more likely than pretravelers to have contraceptive lapses, but indicated that they were more likely to report a new male partner (relative risk, 1.7). Most participants (80%) had a regular source of sexual and reproductive health care; 42% of travelers had seen a health care provider in preparation for their trip. CONCLUSION: If the findings are corroborated by additional research, they may suggest a role for health care providers in students' pretravel period.

A motivational interviewing-based counseling intervention to increase postabortion uptake of contraception: A pilot randomized controlled trial.

OBJECTIVE: To determine if a counseling intervention using the principles of motivational interviewing (MI) would impact uptake of long-acting reversible contraception (LARC) after abortion. METHODS: We conducted a pilot randomized controlled trial comparing an MI-based contraception counseling intervention to only non-standardized counseling. Sixty women 15-29 years-old were randomized. PRIMARY OUTCOME: uptake of LARC within four weeks of abortion. SECONDARY OUTCOMES: uptake of any effective contraceptive, contraceptive use three months after abortion and satisfaction with counseling. Bivariate analysis was used to compare outcomes. RESULTS: In the intervention arm, 65.5% of participants received a long-acting method within four weeks compared to 32.3% in the control arm (p=0.01). Three months after the abortion, differences in LARC use endured (60.0% vs. 30.8%, p=0.05). Uptake and use of any effective method were not statistically different. More women in the intervention arm reported satisfaction with their counseling than women in the control arm (92.0% vs. 65.4%, p=0.04). CONCLUSION: Twice as many women in the MI-based contraception counseling intervention initiated and continued to use LARC compared to women who received only non-standardized counseling. PRACTICE IMPLICATIONS: A contraception counseling session using the principles and skills of motivational interviewing has the potential to impact LARC use after abortion.

Differences in Family Planning Services by Rural-urban Geography: Survey of Title X-Supported Clinics In Great Plains and Midwestern States.

CONTEXT: Understanding the nature of rural-urban variation in U.S. family planning services would help address disparities in unmet contraceptive need. METHODS: In 2012, some 558 Title X-supported clinics in 16 Great Plains and Midwestern states were surveyed. Rural-urban commuting area (RUCA) codes were used to categorize clinic locations as urban, large rural city, small rural town or isolated small rural town. Bivariate analyses examined key domains of service provision by RUCA category and clinic type. RESULTS: The proportion of clinics offering walk-in appointments was lower in isolated small rural towns (47%) than in the other RUCA categories (67-73%). Results were similar for sites that do not specialize in family planning or reproductive health, but no variation was seen among specialty clinics. Overall, availability of evening or weekend appointments varied in a linear fashion, falling from 73% in urban areas to 29% in isolated small rural towns. On-site provision of most hormonal methods was most common in urban areas and least common in isolated small rural towns, while provision of nonhormonal methods was similar across RUCA categories. Sixty percent of clinics provided IUDs or implants. For clinics that did not, the only barriers that varied geographically were low IUD demand and lack of trained IUD providers; these barriers were most common in isolated rural towns (42% and 70%, respectively). CONCLUSIONS: While important characteristics, such as clinics' specialization (or lack thereof), are linked to the provision of family planning services, geographic disparities exist.

Postpartum Contraception Use by Urban/Rural Status: An Analysis of the Michigan Pregnancy Risk Assessment Monitoring System Data.

OBJECTIVE: We sought to examine rural/urban differences in postpartum contraceptive use, which are underexplored in the literature. METHODS: We analyzed phase 5 (2004-2008) of the Michigan Pregnancy Risk Assessment Monitoring System (PRAMS) survey. Using Rural-Urban Commuting Area codes and weighted multinomial logistic regression, we examined the association between self-reported postpartum contraceptive method and rural/urban residence among postpartum women not desiring pregnancy (n = 6,468). RESULTS: Postpartum (mean, 16.5 weeks after delivery), 14.4% of respondents were using sterilization, 6.7% long-acting reversible contraception (LARC), 37.3% moderately effective hormonal methods, 38.4% less effective methods or no method, and 3.2% abstinence. Multivariable analysis yielded sporadic geographic patterns. Odds of method use varied significantly by age, parity, body mass index, and breastfeeding status. Not discussing contraception with a prenatal healthcare provider decreased odds of postpartum LARC use (odds ratio, 0.52; 95% CI, 0.36-0.75). Number of prenatal visits and weeks since delivery were not associated with postpartum contraception method. CONCLUSIONS: We did not observe strong variation in postpartum contraceptive use based on geography. Low uptake of highly effective contraception across rural and urban areas suggests a need for education and outreach regarding these methods.

Correlates of Heterosexual Anal Intercourse among Women in the 2006-2010 National Survey of Family Growth.

INTRODUCTION: Heterosexual anal intercourse (HAI) is common among U.S. women. Receptive anal intercourse is a known risk factor for HIV, yet there is a paucity of data on HAI frequency and distribution in the United States. Condom use is lower with HAI vs. vaginal intercourse, but little is known regarding of correlates of HAI with and without condoms. AIMS: The aims of this study were to describe recent (past 12 months) and lifetime HAI among sexually active reproductive-aged U.S. women, and to characterize women who engage in HAI with and without condoms. METHODS: We analyzed a sample of 10,463 heterosexually active women aged 15-44 years for whom anal intercourse data were available in the 2006-2010 National Survey of Family Growth. MAIN OUTCOME MEASURES: Weighted bivariate and multivariable analyses were used to determine HAI prevalence and correlates. Primary outcomes were lifetime HAI, recent (last 12 months) HAI, and condom use at last HAI. RESULTS: In our sample, 13.2% of women had engaged in recent HAI and 36.3% in lifetime HAI. Women of all racial and ethnic backgrounds and religions reported recent anal intercourse. Condom use was more common at last vaginal intercourse than at last anal intercourse (28% vs. 16.4%, P < 0.001). In multivariable analysis, correlates of recent HAI included: less frequent church attendance, younger age at first intercourse, multiple sexual partners, history of oral intercourse, history of unintended pregnancy, and treatment for sexually transmitted infections (all P < 0.05). Correlates of lifetime HAI were similar, with the addition of older age, higher education, higher income, and history of drug use (all P < 0.05). CONCLUSION: Women of all ages and ethnicities engage in HAI, at rates higher than providers might realize. Condom use is significantly lower for HAI vs. vaginal intercourse, putting these women at risk for acquisition of sexually transmitted infections.

Intrauterine device use in an urban university clinic: safety of use in a population at high risk for sexually transmitted infections.

OBJECTIVE: The objective was to describe infection rates after intrauterine device (IUD) placement at an urban teaching hospital that did not restrict IUD eligibility based on risk factors for sexually transmitted infections (STIs). METHODS: We reviewed charts of patients undergoing IUD placement at the University of Chicago obstetrics and gynecology resident clinic from July 2007 to June 2008 (n=283). The primary outcome was diagnosis of pelvic inflammatory disease (PID) within 12 months. RESULTS: Almost half (49.5%) of patients reported a history of any STI. Two patients (0.7%) were diagnosed with PID. CONCLUSION: Postplacement infection in this unrestricted population was infrequent and comparable to reported rates in previous studies.

Impact of a theory-based video on initiation of long-acting reversible contraception after abortion.

OBJECTIVE: Adoption of long-acting reversible contraception (LARC) (ie, the intrauterine device or the contraceptive implant) immediately after abortion is associated with high contraceptive satisfaction and reduced rates of repeat abortion. Theory-based counseling interventions have been demonstrated to improve a variety of health behaviors; data on theory-based counseling interventions for postabortion contraception are lacking. STUDY DESIGN: Informed by the transtheoretical model of behavioral change, a video intervention was developed to increase awareness of, and dispel misconceptions about, LARC methods. The intervention was evaluated in a randomized controlled trial among women aged 18-29 years undergoing surgical abortion at a clinic in Chicago, IL. Participants were randomized 1:1 to watch the intervention video or to watch a stress management video (control), both 7 minutes in duration. Contraceptive methods were supplied to all participants free of charge. Rates of LARC initiation immediately after abortion were compared. RESULTS: Rates of LARC initiation immediately after abortion were not significantly different between the 2 study arms; 59.6% in the intervention and 51.6% in the control arm chose a LARC method (P = .27). CONCLUSION: This study resulted in an unexpectedly high rate of LARC initiation immediately after abortion. High rates of LARC initiation could not be attributed to a theory-based counseling intervention.

Doula support during first-trimester surgical abortion: a randomized controlled trial.

OBJECTIVE: The objective of the study was to evaluate the impact of doula support on first-trimester abortion care. STUDY DESIGN: Women were randomized to receive doula support or routine care during first-trimester surgical abortion. We examined the effect of doula support on pain during abortion using a 100 mm visual analog scale. The study had the statistical power to detect a 20% difference in mean pain scores. Secondary measures included satisfaction, procedure duration, and patient recommendations regarding doula support. RESULTS: Two hundred fourteen women completed the study: 106 received doula support, and 108 received routine care. The groups did not differ regarding demographics, gestational age, or medical history. Pain scores in the doula and control groups did not differ at speculum insertion (38.6 [±26.3 mm] vs 43.6 mm [±25.9 mm], P = .18) or procedure completion (68.2 [±28.0 mm] vs 70.6 mm [±23.5 mm], P = .52). Procedure duration (3.39 [±2.83 min] vs 3.18 min [±2.36 min], P = .55) and patient satisfaction (75.2 [±28.6 mm] vs 74.6 mm [±27.4 mm], P = .89) did not differ between the doula and control groups. Among women who received doula support, 96.2% recommended routine doula support for abortion and 60.4% indicated interest in training as doulas. Among women who did not receive doula support, 71.6% of women would have wanted it. Additional clinical staff was needed to provide support for 2.9% of women in the doula group and 14.7% of controls (P < .01). CONCLUSION: Although doula support did not have a measurable effect on pain or satisfaction, women overwhelmingly recommended it for routine care. Women receiving doula support were less likely to require additional clinic support resources. Doula support therefore may address patient psychosocial needs.

Parent-daughter communication about abortion among nonpregnant African-American adolescent females.

PURPOSE: To identify correlates of parent-daughter communication about abortion among nonpregnant adolescents. METHODS: Nonpregnant African-American females aged 14-17 years attending one of three charter schools on Chicago's South Side were recruited and surveyed regarding parental relationship quality, attitudes toward sexual health, and communication about sexual health. We calculated odds ratios (ORs) for ever discussing abortion using multivariable logistic regression. RESULTS: Of the 265 adolescents, 43.0% had ever discussed abortion with a parent. While 72.3% would voluntarily tell a parent about an abortion plan, 19.2% feared a parent would physically hurt her, punish her, or evict her. Ever communicating about abortion was significantly associated with having a mother who had a teen pregnancy (OR, 1.99; 95% confidence interval [CI], 1.05-3.78); having a prochoice abortion attitude (OR, 3.27; 95% CI, 1.29-8.25); having discussed sexually transmitted infections (OR, 2.97; 95% CI, 1.13-7.77) or birth control (OR, 2.96; 95% CI, 1.35-6.47) with a parent; and perceived parental approval of adolescent sexual activity (OR, 3.07; 95% CI, 1.20-7.88). Ever communicating about abortion was inversely related to being sexually experienced (OR, .48; 95% CI, .23-.99) or anticipating supportive parental reactions to an abortion decision (OR, .31; 95% CI, .13-.75). CONCLUSIONS: Although almost half of our sample was sexually active, the majority had never talked to their parents about abortion. Some reported fears of harm should the situation arise. Public policy should focus on promoting parent-daughter communication before an unwanted pregnancy rather than forcing communication after it occurs.

A systematic approach to improving intrauterine device services in family planning clinics.

OBJECTIVES: To improve the quality of intrauterine device (IUD) services at Title X clinics. STUDY DESIGN: Failure Modes Effects and Criticality Analysis (FMECA) is a step-by-step approach, adopted for healthcare, in which team members evaluate the systems and processes of a specific type of clinical care (e.g., IUD care) in order to identify practices that contribute to poor quality, unsafe, unreliable, or inefficient care. These weaknesses are termed "failures." The FMECA uses qualitative (e.g., meetings) and quantitative (e.g., clinical operations) data to determine failure frequency and impact in order to prioritize the parts of a clinical care system or process to be redesigned and improved. An FMECA was conducted in three community-based Title X family planning clinics on the South and West Sides of Chicago, IL with all care team members; IUD clients were also interviewed regarding their visit. Clinic administrative data was also assessed to determine the frequency and impact of the identified failures. RESULTS: After combining the FMECA and clinical operations data, "critical" areas across all three clinics were: (1) client does not show up for or cancels appointment; (2) client is ineligible for an IUD insertion due to unprotected intercourse; and (3) limited time for counseling, informing, and placing IUDs. As most insertions were successful, failed IUD insertion was not considered a high-risk failure. CONCLUSIONS: This process revealed that the failures most in need of improvement and redesign were the scheduling and intake processes and the lack of time for counseling during certain types of visits. IMPLICATIONS: A systematic assessment of the underlying problems in IUD-care revealed three important issues across three clinics: (1) client does not show up for appointment or cancels appointment; (2) client recently had unprotected intercourse; and (3) limited time for counseling, informing, and placing IUDs.