Abortion Education for Medical Students in an Era of Increased Abortion Restrictions.

Following the Supreme Court's decision in Dobbs v Jackson Women's Health in June 2022, many states restricted or banned abortion. Medical educators have focused on how this change impacts abortion training for residents, but schools must also adapt undergraduate medical education. Medical schools provide the foundation for future physicians' knowledge and attitudes on abortion. Comprehensive, high-quality abortion education for all medical students is essential for the future of abortion care. Here, we present how education champions can lead curricular improvements in abortion education in the preclinical, clerkship, and postclerkship phases of undergraduate medical education.

Abortion and Contraception in Medical School Curricula: A Survey of North American Family Medicine Clinical Curriculum Directors.

Phenomenon: Contraception and abortion care are commonly accessed health services, and physicians in training will encounter patients seeking this care. Curricula that teach contraception and abortion provision during medical school equip medical students with valuable skills and may influence their intention to provide these services during their careers. Family planning is nevertheless understood to be underrepresented in most medical curricula, including in North American medical schools where the laws on providing contraception and abortion have been consequentially changing. This study investigated the prevalence and predictors of contraception and abortion education in North American medical curricula in 2021.Approach: We asked family medicine clerkship directors from Canada and the United States (US) to report about contraception and abortion teaching in their clinical curricula and their school's whole curriculum and to report on associated factors. Survey questions were included in the 2021 Council of Academic Family Medicine's Educational Research Alliance (CERA) survey of Family Medicine Clerkship Directors at accredited North American medical schools. Surveys were distributed between April 29 and May 28, 2021, to the 160 clerkship directors listed in the CERA organization database.Findings: Seventy-eight directors responded to the survey (78/160, 48%). 47% of responding directors reported no contraception teaching in the family medicine clerkship. 81.7% of responding directors reported no abortion teaching in the clerkship, and 66% indicated abortion was not being taught in their school's whole curriculum. Medical school region correlated with the presence of abortion curricula, and schools with high graduation rates into the family medicine specialty reported abortion teaching more frequently. Fewer than 40% of responding directors had received training on both contraception and abortion care themselves.Insights: Contraception and abortion are both underrepresented in North American medical curricula. Formal abortion education may be absent from most family medicine clerkships and whole program curricula. To enhance family planning teaching in North American medical schools, we recommend that national curriculum resources be revised to include specific contraception and abortion learning objectives and for increased development and support for clinical curricula directors to universally include family planning teaching in whole program and family medicine clerkship curricula.

Intrauterine devices are a safe form of contraception in users with solid organ transplantation: A single-center experience.

Patients who undergo organ transplantation are advised to use contraception for health optimization, yet limited data exists on safe contraceptive options for this population. This study investigates the infection risk of intrauterine devices (IUDs) in patients who have received a solid organ transplant by evaluating the incidence of pelvic inflammatory disease (PID). We performed a retrospective chart review of subjects with a solid organ transplant who used an IUD between the years of January 2007 to February 2021. We included subjects ages 22-55 years at the time of IUD placement. We abstracted demographic information, transplant type, IUD type, immunosuppressive medications, screening for sexually transmitted infections, and diagnosis of PID. We identified 29 subjects that met the inclusion criteria. Six subjects had a copper IUD (21%) and 23 had a levonorgestrel IUD (79%). The most common organ transplanted was a kidney (n = 10) and liver (n = 10) while five subjects had multiple organs transplanted. Twenty-five (86.2%) subjects took immunosuppressive medications at the time of IUD insertion. Twenty-four (82.8%) patients had their IUD placed after transplantation. The average time of IUD use was 2.5 years. . In our study of IUD use in patients with solid organ transplantation, no patients developed PID. IUDs are a safe contraceptive option for immunosuppressed transplant patients.

TEAD4 ensures postimplantation development by promoting trophoblast self-renewal: An implication in early human pregnancy loss.

Early pregnancy loss affects ∼15% of all implantation-confirmed human conceptions. However, evolutionarily conserved molecular mechanisms that regulate self-renewal of trophoblast progenitors and their association with early pregnancy loss are poorly understood. Here, we provide evidence that transcription factor TEAD4 ensures survival of postimplantation mouse and human embryos by controlling self-renewal and stemness of trophoblast progenitors within the placenta primordium. In an early postimplantation mouse embryo, TEAD4 is selectively expressed in trophoblast stem cell-like progenitor cells (TSPCs), and loss of Tead4 in postimplantation mouse TSPCs impairs their self-renewal, leading to embryonic lethality before embryonic day 9.0, a developmental stage equivalent to the first trimester of human gestation. Both TEAD4 and its cofactor, yes-associated protein 1 (YAP1), are specifically expressed in cytotrophoblast (CTB) progenitors of a first-trimester human placenta. We also show that a subset of unexplained recurrent pregnancy losses (idiopathic RPLs) is associated with impaired TEAD4 expression in CTB progenitors. Furthermore, by establishing idiopathic RPL patient-specific human trophoblast stem cells (RPL-TSCs), we show that loss of TEAD4 is associated with defective self-renewal in RPL-TSCs and rescue of TEAD4 expression restores their self-renewal ability. Unbiased genomics studies revealed that TEAD4 directly regulates expression of key cell cycle genes in both mouse and human TSCs and establishes a conserved transcriptional program. Our findings show that TEAD4, an effector of the Hippo signaling pathway, is essential for the establishment of pregnancy in a postimplantation mammalian embryo and indicate that impairment of the Hippo signaling pathway could be a molecular cause for early human pregnancy loss.

Atypical protein kinase C iota (PKCλ/ι) ensures mammalian development by establishing the maternal-fetal exchange interface.

In utero mammalian development relies on the establishment of the maternal-fetal exchange interface, which ensures transportation of nutrients and gases between the mother and the fetus. This exchange interface is established via development of multinucleated syncytiotrophoblast cells (SynTs) during placentation. In mice, SynTs develop via differentiation of the trophoblast stem cell-like progenitor cells (TSPCs) of the placenta primordium, and in humans, SynTs are developed via differentiation of villous cytotrophoblast (CTB) progenitors. Despite the critical need in pregnancy progression, conserved signaling mechanisms that ensure SynT development are poorly understood. Herein, we show that atypical protein kinase C iota (PKCλ/ι) plays an essential role in establishing the SynT differentiation program in trophoblast progenitors. Loss of PKCλ/ι in the mouse TSPCs abrogates SynT development, leading to embryonic death at approximately embryonic day 9.0 (E9.0). We also show that PKCλ/ι-mediated priming of trophoblast progenitors for SynT differentiation is a conserved event during human placentation. PKCλ/ι is selectively expressed in the first-trimester CTBs of a developing human placenta. Furthermore, loss of PKCλ/ι in CTB-derived human trophoblast stem cells (human TSCs) impairs their SynT differentiation potential both in vitro and after transplantation in immunocompromised mice. Our mechanistic analyses indicate that PKCλ/ι signaling maintains expression of GCM1, GATA2, and PPARγ, which are key transcription factors to instigate SynT differentiation programs in both mouse and human trophoblast progenitors. Our study uncovers a conserved molecular mechanism, in which PKCλ/ι signaling regulates establishment of the maternal-fetal exchange surface by promoting trophoblast progenitor-to-SynT transition during placentation.

Availability of ulipristal acetate: A secret shopper survey of pharmacies in a metropolitan area on emergency contraception.

OBJECTIVES: To assess levonorgestrel (LNG) and ulipristal acetate (UPA) availability in pharmacies in a metropolitan area. METHODS: A cross-sectional survey was conducted of all identified pharmacies within 25 miles of an urban medical center in Kansas City, KS. We categorized the pharmacies as dedicated commercial (national chains), store-associated (affiliated with a general merchandise or grocery store), or independent. We assessed LNG and UPA availability or time to availability if not currently stocked. RESULTS: We contacted 165 pharmacies. Of the 165 pharmacies, few stocked UPA (12/165, 7%) whereas the majority stocked oral LNG (128/165, 78%). Dedicated commercial pharmacies were more likely to carry UPA than store-associated and independent pharmacies (11/84 [13%] vs. 1/61 [1%] vs. 0/20, respectively; P = 0.016). Most pharmacies that did not stock UPA reported that they could obtain it within 24 hours (94/153, 62%). Dedicated commercial pharmacies were most likely report the ability to obtain UPA in 24 hours (P = 0.016). CONCLUSION: Few pharmacies stock UPA, the most effective form of oral emergency contraception. Enhanced communication between medical providers and pharmacists within current laws and regulations could enhance patient access to UPA.

Sexual and reproductive health teaching in undergraduate medical education: A narrative review.

OBJECTIVE: Contraception use, undesired pregnancy, and abortion care are common medical experiences that most physicians will encounter for their patients. Future physicians should therefore have some formal education on these topics. In this narrative review, we focused on how medical education approaches these sometimes polarizing yet fundamental topics. METHODS: We assessed the published literature on sexual and reproductive health education in undergraduate medical education from 2000 to 2021, screening 868 articles and including 52 articles. We included articles that discussed contraception, emergency contraception, pregnancy options counseling, abortion, and ethics related to sexual and reproductive health. RESULTS: Included studies came from 14 countries and described both preclinical and clinical education. Studies assessed medical student knowledge, the effectiveness of educational interventions and medical school faculty perspectives on sexual and reproductive health curricula. Medical educators have employed a variety of approaches to teach sexual and reproductive health including simulation, objective structured clinical examinations, team-based learning, narrative medicine, online modules, and flipped classrooms. CONCLUSION: Students generally received sexual and reproductive health education favorably, demonstrating increased knowledge and comfort with these topics after an education session. Studies also identified curricular gaps and deficiencies in student knowledge, which may indicate a need for improved and consistent medical school education on contraception and abortion.

Rates of complication for dilation and evacuation versus induction of labor in treatment of second trimester intrauterine fetal demise.

OBJECTIVE: To evaluate clinical differences in the safety of dilation and evacuation (D&E) and induction of labor (IOL) for the treatment of intrauterine fetal demise (IUFD) between 14 and 24 weeks gestation. STUDY DESIGNS: A retrospective chart review was conducted at a single institution comparing rates of major and minor complications between patients who undergo D&E and those that undergo IOL in the treatment of IUFD between 14 and 24 weeks gestation. Demographic and medical variables were stratified by management method and analyzed using chi-squared and t-tests where appropriate. RESULTS: Patients who underwent IOL were of a more advanced gestational age and more likely to be uninsured. Patients who underwent D&E were more likely to be privately insured. Hospital time for an IOL was significantly longer than for D&E. Composite rates of complication did not differ significantly between management groups. Patients treated with D&E were more likely to require uterine aspiration. CONCLUSIONS: D&E and IOL are equally safe methods for the management of IUFD between 14 and 24 weeks gestation. Both options should be made available to patients who experience this rare pregnancy outcome.

Provision of Onsite Childcare in US Academic Health Centers: What Factors Make a Difference?

INTRODUCTION: Challenges to work-life balance, including childcare, have been cited as major barriers to career advancement for women in academic medicine. METHODS: We performed a cross-sectional study to investigate the availability of onsite childcare at academic health centers (AHCs) for US medical schools and examined institutional characteristics associated with its provision. Data from the Association of American Medical Colleges (AAMC) were used to identify US medical schools by region, type (private vs. public, community-based vs. not), financial relationship to the university, and numbers of female medical students, faculty, chairs, and deans. We assessed onsite childcare from publicly available information on institutional websites, plus phone calls to human resources departments at medical centers and/or medical schools. RESULTS: Our study identified 144 US medical schools from the AAMC database and collected complete data for 136 (95%). Most AHCs offered onsite childcare (62%, 84/136). AHCs in the Midwest (78%) were most likely to have onsite childcare, whereas AHCs in the Southwest were least likely (14%, p < .001). No associations were demonstrated between onsite childcare and the proportion of female chairs or female faculty, or the AHC's financial relationship with the parent university. CONCLUSIONS: Although accessible childcare is critical to the upward mobility of women in medicine, more than a third of AHCs do not offer onsite childcare. As more women in medicine navigate childcare demands, the expansion of accessible, quality onsite childcare at AHCs is needed to promote a diverse academic workforce.

Hydatidiform Mole with Coexisting Fetus and Syndrome of Inappropriate Antidiuretic Hormone Secretion: A Case Report.

CONTEXT: Molar pregnancies have been associated with hyperthyroidism and hypertensive disorders. Coexisting molar and fetal pregnancies, which are very rare, have an even higher risk of complications. CASE DESCRIPTION: We describe a case of hyponatremia due to syndrome of inappropriate antidiuretic hormone secretion (SIADH) associated with a molar pregnancy. A 36-year-old patient at 13 weeks gestation with a coexisting molar pregnancy presented with headache, nausea, and vomiting. She was found to have hypertension, hyperthyroidism, and hyponatremia. The hyponatremia was further assessed with an isotonic saline challenge which resulted in a diagnosis of SIADH. The patient underwent dilation and curettage and her hyponatremia resolved. She later developed gestational trophoblastic neoplasia. CONCLUSIONS: A molar pregnancy can present with unusual associated conditions, such as SIADH. Hyponatremia in a patient with molar pregnancy may be mistakenly attributed to other side effects of trophoblastic tissue (hyperthyroidism, pre-eclampsia, or hyperemesis gravidarum). Hyponatremia in a patient with a molar pregnancy warrants evaluation for SIADH.

Initiation of Postpartum Contraception by 90 Days at a Midwest Academic Center.

INTRODUCTION: Contraception is a critical component of addressing the health needs of women in the postpartum period. We assessed contraception initiation by 90 days postpartum at a large, academic medical center in the Midwest. METHODS: In this retrospective cohort study, 299 charts were randomly sampled and 231 were analyzed from deliveries between May 1 to July 5, 2018. Contraceptive method, maternal demographics, and obstetric characteristics at hospital discharge were collected, as well as contraceptive method at the postpartum follow-up appointment. Methods and strata of contraception were categorized as follows: 1) highly effective methods (HEM) defined as sterilization, intrauterine device, or implant, 2) moderately effective methods (MEM) defined as injectable contraception, progestin-only pills, and combined estrogen/progestin pills, patches, and rings, and 3) less effective methods (LEM) defined as condoms, natural family planning, and lactational amenorrhea. Women lost to follow-up who had initiated a HEM or injectable contraception were coded as still using the method at 90 days. We used logistic regression to identity factors associated with HEM use. RESULTS: Of the 231 included patients, 118 (51%) received contraception before hospital discharge and 166 (83%) by 90 days postpartum. Postpartum visits were attended by 74% (171/231) of patients. Before hospital discharge, 28% (65/231) obtained a HEM and 41% (82/200) were using a HEM by 90 days postpartum. Patients obtaining HEM or injectable contraception before hospital discharge attended a follow-up visit less often than those who did not receive HEM before discharge (RR = 0.68, 95% CI: 0.54 - 0.86, p ≤ 0.01). CONCLUSION: When readily available, many women will initiate contraception in the postpartum period. Health systems should work to ensure comprehensive access to contraception for women in the postpartum period.

Access to contraception in local health departments, four Midwest states, 2017-2018.

OBJECTIVE: Describe contraception availability at local health departments (LHDs) serving largely rural populations. STUDY DESIGN: We invited administrators at LHDs located in four Midwest states to participate in an online survey conducted from September 2017-April 2018. We collected data on clinic staffing, patient population, receipt of Title X funds, and services provided to assess the proportion of LHDs providing any prescription method of contraception; secondary outcomes included healthcare staff training level and other reproductive health services provided. RESULTS: Of 344 LHDs invited, 237 administrators completed the survey (68.9%). Three-quarters served rural populations. One-third (34.6%) provided short-acting hormonal contraception; however, availability varied by state (Kansas: 58.0%, 40/69; Missouri: 37.5%, 33/88; Nebraska: 16.7%, 3/18; Iowa: 9.7%, 6/62; p<.01). Only 8.4% of LHDs provided IUDs; 7.6% provided implants, and 5.9% provided both methods. LHDs in Nebraska and Kansas provided any long-acting method more frequently (Kansas: 17.4%, Nebraska: 16.7%, Iowa: 8.1%, Missouri: 4.6%; p=.04). LHDs receiving Title X funds (27.0%) were much more likely to provide any prescription contraception (85.1% vs. 14.2%, p<.01). Most LHDs relied on registered nurses (RNs) to provide medical care; 81.0% reported that RNs provided care≥20 days per month. Pregnancy testing was widely available in Missouri and Kansas (>87%) and less commonly available in Iowa and Nebraska (<18%) (p<.01). CONCLUSION: LHDs in these states are currently ill-equipped to offer comprehensive contraceptive services. Women seeking care at LHDs have limited, if any, contraceptive options. IMPLICATIONS: Local health departments in the Midwest, serving a largely rural population, rarely offer prescription contraception, especially long-acting reversible methods. Women residing in settings without broad access to publicly-funded healthcare providers may have limited access to comprehensive contraceptive services. Efforts to ensure rural access are needed.

Access to emergency contraception in Kansas City clinics.

OBJECTIVE: To assess the accessibility of ulipristal acetate (UPA) and copper intrauterine devices (IUDs) for emergency contraception (EC) in reproductive health centers in the Kansas City metropolitan area. STUDY DESIGN: Using a secret shopper method, two female investigators called the reproductive health centers listed as EC providers on the nonprofit website bedsider.org that were located within 25 miles of the University of Kansas Medical Center. We categorized clinics as Title X providers vs. not according to the grantee list from the Office of Population Affairs. Investigators inquired about obtaining a UPA prescription by phone, the availability of the copper IUD for EC and time to first available appointment for EC. We evaluated correlates of EC access and provision with Fisher's Exact Tests. RESULTS: We identified 40 clinics as potential EC providers. Some clinics reported that UPA could be prescribed by phone to existing patients (13/40, 32%), while others reported that women must meet with a provider first (15/40, 38%). Few clinics offered copper IUDs as EC (3/40, 8%). Title X clinic status did not predict provision of UPA by phone or copper IUDs as EC. The average time to next available appointment was 9±9 days to discuss EC and 13±9 days for a copper IUD. CONCLUSIONS: Accessing the most efficacious forms of EC in a timely fashion presents many logistic challenges for women. IMPLICATIONS: Healthcare systems should streamline protocols, train providers and improve rapid-access referral networks to facilitate timely provision of UPA and copper IUDs for EC.

"She's on her own": a thematic analysis of clinicians' comments on abortion referral.

OBJECTIVE: The objective was to understand the motivations around and practices of abortion referral among women's health providers. METHODS: We analyzed the written comments from a survey of Nebraska physicians and advanced-practice clinicians in family medicine and obstetrics-gynecology about their referral practices and opinions for a woman seeking an abortion. We analyzed clinician's responses to open-ended questions on abortion referral thematically. RESULTS: Of the 496 completed surveys, 431 had comments available for analysis. We found four approaches to abortion referral: (a) facilitating a transfer of care, (b) providing the abortion clinic name or phone number, (c) no referral and (4) misleading referrals to clinicians or facilities that do not provide abortion care. Clinicians described many motivations for their manner of referral, including a fiduciary obligation to refer, empathy for the patient, respect for patient autonomy and the lack of need for referral. We found that abortion stigma impacts referral as clinicians explained that patients often desire additional privacy and clinicians themselves seek to avoid tension among their staff. Other clinicians would not provide an abortion referral, citing moral or religious objections or stating they did not know where to refer women seeking abortion. Some respondents would refer women to other providers for additional evaluation or counseling before an abortion, while others sought to dissuade the woman from obtaining an abortion. CONCLUSIONS: While practices and motivations varied, few clinicians facilitated referral for abortion beyond verbally naming a clinic if an abortion referral was made at all. IMPLICATIONS: Interprofessional leadership, enhanced clinician training and public policy that addresses conscientious refusal of abortion referral are needed to reduce abortion stigma and ensure that women can access safe care.

What Women Want from Their Health Care Providers about Pregnancy Options Counseling: A Qualitative Study.

OBJECTIVES: Unintended pregnancy is common in the United States, yet scant research has evaluated women's preferences on pregnancy options counseling. This study explores pregnant women's preferences for pregnancy options counseling from health care providers. METHODS: We conducted semistructured interviews with pregnant women at a prenatal clinic and an abortion clinic. We asked women about recent discussions-or lack thereof-about pregnancy options (parenting, adoption, and abortion) with a clinician, and what they would want their provider to discuss about pregnancy options. We analyzed transcripts using modified grounded theory. FINDINGS: We interviewed 10 women in prenatal care and 18 women seeking abortion. In both settings, most said clinicians should discuss pregnancy options with pregnant women and 1) respect patient autonomy, 2) avoid assumptions about a woman's desired pregnancy outcome, and 3) consider the patient-including her health and fertility intentions-beyond her pregnancy. Participants wanted their doctors to assess a pregnancy's individual circumstances to determine the appropriateness of options counseling. A few participants, including women who did and did not receive options counseling, reported they personally preferred not to receive such counseling. Explaining this preference, they cited preservation of privacy, having already made a decision for the pregnancy, or just not wanting to discuss abortion. Regarding best practices for providing options counseling, participants said it should be done in a routine manner, with discretion, and early in pregnancy. CONCLUSIONS: Pregnant women seeking both prenatal and abortion care broadly support options counseling. IMPLICATIONS: Discussion of pregnancy options, including abortion, provides patient-centered care and supports women's preferences.

Influence of clinician referral on Nebraska women's decision-to-abortion time.

OBJECTIVE: To assess the association of clinician referral with decision-to-abortion time. STUDY DESIGN: We conducted a cross-sectional survey of women seeking abortion at all three Nebraska abortion clinics. We defined referral as direct (information for an abortion clinic), inappropriate (information for a clinic that does not provide abortions) or no referral. Women reported when they recognized their pregnancy, decided to seek abortion and contacted a clinician. The primary outcome - decision-to-abortion time - was time from certain decision to abortion. We used multivariate linear regression analysis, controlling for potential confounders. RESULTS: Participants (n=356) were a mean of 26.8±5.3years old, primarily white (62%), unmarried (88%) and urban (87%), with a mean gestational duration of 8(2/7)weeks (S.D.±20days). Forty-six percent (164) had contacted a clinician and 30% (104) had discussed abortion with one before their abortion. Of those, 30% received a direct referral, 6% received an inappropriate referral and 64% received no referral. Decision-to-abortion time did not vary by referral type [mean difference compared with direct referral: inappropriate referral, 1.1days, 95% confidence interval (CI) -13.4 to 15.6, p=.88; no referral, -0.4days, 95% CI -7.0 to 6.3]. The most common reasons cited for delay in obtaining an abortion were an inability to get an earlier appointment (105/263, 40%) and time needed to raise money to pay for the abortion (73/263, 28%). CONCLUSION: While neither occurrence of referral nor type was associated with decision-to-abortion times, women in Nebraska continue to face barriers to timely abortion care. IMPLICATIONS: Additional research is needed to explore whether quality clinician referral improves abortion access and whether increased resources should be dedicated to improving referral patterns.

Contraception and fertility awareness among women with solid organ transplants.

OBJECTIVE: To assess the contraception and fertility counseling provided to women with solid organ transplants. METHODS: A telephone survey of 309 women aged 19-49 years who had received a solid organ transplant at the University of Nebraska Medical Center was performed. Of the 309 eligible women, 183 responded. Patients were asked 19 questions regarding pretransplant and posttransplant fertility awareness and contraception counseling. Data were summarized using descriptive statistics. RESULTS: Patients had undergone a variety of solid organ transplantations: 40% kidney (n=73); 32% liver (n=59); 6% pancreas (n=11); 5% heart (n=9); 3% intestine (n=5); and 14% multiple organs (n=26). Before their transplantations, 79 women (44%) reported they were not aware that a woman could become pregnant after transplantation. Only 66 women aged 13 and older at the time of transplantation reported that a health care provider discussed contraception before transplantation. Approximately half of women surveyed were using a method of contraception. Oral contraceptive pills were the most commonly recommended method. Twenty-two of the 31 pregnancies after organ transplantation were planned, which is higher than that of the general population. CONCLUSION: Few women with transplants are educated regarding the effect of organ transplantation on fertility and are not routinely counseled about contraception or the potential for posttransplant pregnancy. Health care providers should incorporate contraceptive and fertility counseling as part of routine care for women with solid organ transplants. LEVEL OF EVIDENCE: : II.