Measuring a Critical Component of Contraceptive Decision Making: The Contraceptive Concerns and Beliefs Scale.

INTRODUCTION: Concerns about safety and side effects from contraceptives are widespread and related to reluctance to use them. Measuring these concerns is an essential component of understanding contraceptive decision-making and guiding contraceptive and interpregnancy clinical care. METHODS: We used qualitative research and item response theory to develop and test a psychometric instrument to measure contraceptive concerns and beliefs. We developed 55 candidate scale items and tested them among 572 adolescents and adults across nine California healthcare facilities in 2019-2020. We derived a 6-item scale and assessed differences by age and social determinants of health with multivariable regression. RESULTS: In qualitative data, participants voiced both concerns and positive beliefs about contraception. Quantitative survey respondents were aged 21 years on average, and 24% were parous. Over half (54%) worried contraception has dangerous side effects, and 39% worried it is unnatural. The mean Contraceptive Concerns score, increasing with higher concerns, was 1.85 (SD: 1.00, range 0-4, α = 0.81). Items fit a partial credit item response model and met prespecified criteria for internal structure validity. Contraceptive use declined with increasing Concerns score (adjusted prevalence ratio [aPR] = 0.81 [0.72-0.92]). Scores were elevated among Black (mean: 2.06; aß = 0.34 [0.09, 0.59]) and Multiracial or other race (2.11; aß = 0.34 [0.02, 0.66]) respondents vs. White (1.66), but not Latinx respondents (1.81; aß = 0.11 [- 0.11, 0.33]). Scores were also elevated among participants with lower maternal education (high school/Associate's 1.89 versus college 1.60; aß = 0.28 [0.04, 0.53]). DISCUSSION: The psychometrically robust Concerns instrument can be used in research to measure autonomous contraceptive decision-making and to design person-centered care.

Agency in Contraceptive Decision-Making in Patient Care: a Psychometric Measure.

BACKGROUND: Patient agency in contraceptive decision-making is an essential component of reproductive autonomy. OBJECTIVE: We aimed to develop a psychometrically robust measure of patient contraceptive agency in the clinic visit, as a measure does not yet exist. DESIGN: For scale development, we generated and field tested 54 questionnaire items, grounded in qualitative research. We used item response theory-based methods to select and evaluate scale items for psychometric performance. We iteratively examined model fit, dimensionality, internal consistency, internal structure validity, and differential item functioning to arrive at a final scale. PARTICIPANTS: A racially/ethnically diverse sample of 338 individuals, aged 15-34 years, receiving contraceptive care across nine California clinics in 2019-2020. MAIN MEASURES: Contraceptive Agency Scale (CAS) of patient agency in preventive care. KEY RESULTS: Participants were 20.5 mean years, with 36% identifying as Latinx, 26% White, 20% Black, 10% Asian/Native Hawaiian/Pacific Islander. Scale items covered the domains of freedom from coercion, non-judgmental care, and active decision-making, and loaded on to a single factor, with a Cronbach's α of 0.80. Item responses fit a unidimensional partial credit item response model (weighted mean square statistic within 0.75-1.33 for each item), met criteria for internal structure validity, and showed no meaningful differential item functioning. Most participants expressed high agency in their contraceptive visit (mean score 9.6 out of 14). One-fifth, however, experienced low agency or coercion, with the provider wanting them to use a specific method or to make decisions for them. Agency scores were lowest among Asian/Native Hawaiian/Pacific Islander participants (adjusted coefficient: -1.5 [-2.9, -0.1] vs. White) and among those whose mothers had less than a high school education (adjusted coefficient; -2.1 [-3.3, -0.8] vs. college degree or more). CONCLUSIONS: The Contraceptive Agency Scale can be used in research and clinical care to reinforce non-coercive service provision as a standard of care.

Predictive ability of the Desire to Avoid Pregnancy scale.

BACKGROUND: A longstanding gap in the reproductive health field has been the availability of a screening instrument that can reliably predict a person's likelihood of becoming pregnant. The Desire to Avoid Pregnancy Scale is a new measure; understanding its sensitivity and specificity as a screening tool for pregnancy as well as its predictive ability and how this varies by socio-demographic factors is important to inform its implementation. METHODS: This analysis was conducted on a cohort of 994 non-pregnant participants recruited in October 2018 and followed up for one year. The cohort was recruited using social media as well as advertisements in a university, school, abortion clinic and outreach sexual health service. Almost 90% of eligible participants completed follow-up at 12 months; those lost to follow-up were not significantly different on key socio-demographic factors. We used baseline DAP score and a binary variable of whether participants experienced pregnancy during the study to assess the sensitivity, specificity, area under the ROC curve (AUROC) and positive and negative predictive values (PPV and NPV) of the DAP at a range of cut-points. We also examined how the predictive ability of the DAP varied according to socio-demographic factors and by the time frame considered (e.g., pregnancy within 3, 6, 9 and 12 months). RESULTS: At a cut-point of 2 on the 0-4 range of the DAP scale, the DAP had a sensitivity of 0.78, a specificity of 0.81 and an excellent AUROC of 0.87. In this sample the cumulative incidence of pregnancy was 16% (95%CI 13%, 18%) making the PPV 43% and the NPV 95% at this cut-point. The DAP score was the factor most strongly associated with pregnancy, even after age and number of children were taken into account. The association between baseline DAP score and pregnancy did not differ across time frames. CONCLUSIONS: This is the first study to assess the DAP scale as a screening tool and shows that its predictive ability is superior to the limited pre-existing pregnancy prediction tools. Based on our findings, the DAP could be used with a cut-point selected according to the purpose.

Delayed Visits for Contraception Due to Concerns Regarding Pelvic Examination Among Women with History of Intimate Partner Violence.

BACKGROUND: Concern regarding pelvic examinations may be more common among women experiencing intimate partner violence. OBJECTIVE: We examined women's attitudes towards pelvic examination with history of intimate partner violence (pressured to have sex, or verbal, or physical abuse). DESIGN: Secondary analysis of data from a cluster randomized trial on contraceptive access. PARTICIPANTS: Women aged 18-25 were recruited at 40 reproductive health centers across the USA (2011-2013). MAIN MEASURES: Delays in clinic visits for contraception and preference to avoid pelvic examinations, by history of ever experiencing pressured sex, verbal, or physical abuse from a sexual partner, reported by frequency (never, rarely, sometimes, often). We used multivariable logistic regression with generalized estimating equations for clustered data. KEY RESULTS: A total of 1490 women were included. Ever experiencing pressured sex was reported by 32.4% of participants, with 16.5% reporting it rarely, 12.1% reporting it sometimes, and 3.8% reporting it often. Ever experiencing verbal abuse was reported by 19.4% and physical abuse by 10.2% of participants. Overall, 13.2% of participants reported ever having delayed going to the clinic for contraception to avoid having a pelvic examination, and 38.2% reported a preference to avoid pelvic examinations. In multivariable analysis, women reporting that they experienced pressured sex often had significantly higher odds of delaying a clinic visit for birth control (aOR 3.10 95% CI 1.39-6.84) and for reporting a preference to avoid pelvic examinations (aOR 2.91 95% CI 1.57-5.40). We found no associations between delay of clinic visits or preferences to avoid a pelvic examination and verbal or physical abuse. CONCLUSIONS: History of pressured sex from an intimate partner is common. Among women who have experienced pressured sex, concern regarding pelvic examinations is a potential barrier to contraception. Communicating that routine pelvic examinations are no longer recommended by professional societies could potentially reduce barriers and increase preventive healthcare visits.

Measuring Men's Gender Norm Beliefs Related to Contraception: Development of the Masculine Norms and Family Planning Acceptance Scale.

Male partner resistance is identified as a key factor that influences women's contraceptive use. Examination of the masculine norms that shape men's resistance to contraception-and how to intervene on these norms-is needed. To assess a gender-transformative intervention in Kenya, we developed and evaluated a masculinity-informed instrument to measure men's contraceptive acceptance-the Masculine Norms and Family Planning Acceptance (MNFPA) scale. We developed draft scale items based on qualitative research and administered them to partnered Kenyan men (n = 150). Item response theory-based methods were used to reduce and psychometrically evaluate final scale items. The MNFPA scale had a Cronbach's α of 0.68 and loaded onto a single factor. MNFPA scores were associated with self-efficacy and intention to accept a female partner's use of contraception; scores were not associated with current contraceptive use. The MNFPA scale is the first rigorously developed and psychometrically evaluated tool to assess men's contraceptive acceptance as a function of male gender norms. Future work is needed to test the MNFPA measure in larger samples and across different contexts. The scale can be used to evaluate interventions that seek to shift gender norms to increase men's positive engagement in pregnancy spacing and prevention.

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

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

Effects of Carrying an Unwanted Pregnancy to Term on Women's Existing Children.

OBJECTIVE: To examine how receiving or being denied a wanted abortion affects the subsequent development, health, caregiving, and socioeconomics of women's existing children at time of seeking abortion. STUDY DESIGN: The Turnaway Study is a 5-year longitudinal study with a quasi-experimental design. Women were recruited from January 2008 to December 2010 from 30 abortion facilities throughout the US. We interviewed women regarding the health and development of their living children via telephone 1 week after seeking an abortion and semiannually for 5 years. We compare the youngest existing children younger than the age 5 years of women denied abortion because they presented for care beyond a facility's gestational limit (Turnaway group) with those of women who received the abortion (Abortion group). We used mixed-effects regression models to test for differences in outcomes of existing children of women in the Turnaway group (n = 55 children) compared with existing children of women in the Abortion group (n = 293 children). RESULTS: From 6 months to 4.5 years after their mothers sought abortions, existing children of women denied abortions had lower mean child development scores (adjusted ß -0.04, 95% CI -0.07 to -0.00) and were more likely to live below the Federal Poverty Level (aOR 3.74, 95% CI 1.59-8.79) than the children of women who received a wanted abortion. There were no significant differences in child health or time spent with a caregiver other than the mother. CONCLUSIONS: Denying women a wanted abortion may have negative developmental and socioeconomic consequences for their existing children.

Psychometric Evaluation of an Instrument to Measure Prospective Pregnancy Preferences: The Desire to Avoid Pregnancy Scale.

BACKGROUND: Existing approaches to measuring women's pregnancy intentions suffer important limitations, including retrospective assessment, overly simple categories, and a presumption that all women plan pregnancies. No psychometrically valid scales exist to prospectively measure the ranges of women's pregnancy preferences. MATERIALS AND METHODS: Using a rigorous construct modeling approach, we developed a scale to measure desire to avoid pregnancy. We developed 60 draft items from existing research, assessed comprehension through 25 cognitive interviews, and administered items in surveys with 594 nonpregnant women in 7 primary and reproductive health care facilities in Arizona, New Jersey, New Mexico, South Carolina, and Texas in 2016-2017. We used item response theory to reduce the item set and assess the scale's reliability, internal structure validity, and external validity. Items were included based on fit to a random effects multinomial logistic regression model (partial credit item response model), correspondence of item difficulty with participants' pregnancy preference levels, and consistency of each item's response options with overall scale scores. RESULTS: The 14 final items covered 3 conceptual domains: cognitive preferences, affective feelings, and practical consequences. Items fit the unidimensional model, with a separation reliability of 0.90 (Cronbach α: 0.95). The scale met established criteria for internal validity, including correspondence between each item's response categories and overall scale scores. We found no important differential item functioning by participant characteristics. CONCLUSIONS: A robust measure is available to prospectively measure desire to avoid pregnancy. The measure can aid in identifying women who could benefit from contraceptive care and research on less desired pregnancy.

Stability of Retrospective Pregnancy Intention Reporting Among Women with Unwanted Pregnancies in the United States.

Objectives Retrospective assessment of pregnancy intention may be unreliable as women's perceptions of a past conception can change over time. We compared the stability of retrospective pregnancy intention reporting over 5 years among women who sought and either received, or were denied, an abortion. Methods We recruited women from 30 abortion facilities across the United States in 2008-2010. Participants, some who received abortions and others who were denied care because they presented beyond facilities gestational limits, were followed prospectively for 5 years (n = 827). At enrollment and semiannually from year-2 to year-5, women completed the London Measure of Unplanned Pregnancy (LMUP), a six-item measure (scored 0-12), regarding the index pregnancy. We used multivariable mixed-effects models to assess the stability of retrospective reports of index pregnancy intendedness and compared trajectories by group, accounting for site and participant clustering. Our hypotheses were that intention would tend towards "more intended" over time among women denied abortions, who carried the pregnancies to term, and remain stable among women who received the abortion. Results Baseline LMUP scores were low (mean: 2.8) and similar by study group. Scores increased among women denied the abortion by year-2 (from 2.9 to 3.5; p < 0.001) and were steady through year-5. For women having near-limit abortions, reported intentions were steady between baseline (mean: 2.7) and year-2 (2.8), and declined thereafter through year-5 (to 2.5; p < 0.001). Conclusions Women somewhat shifted their perceptions of their intentions in correspondence with the pregnancy outcome. Retrospective estimates may underestimate the degree to which births result from unintended pregnancy.

Training contraceptive providers to offer intrauterine devices and implants in contraceptive care: a cluster randomized trial.

BACKGROUND: US unintended pregnancy rates remain high, and contraceptive providers are not universally trained to offer intrauterine devices and implants to women who wish to use these methods. OBJECTIVE: We sought to measure the impact of a provider training intervention on integration of intrauterine devices and implants into contraceptive care. STUDY DESIGN: We measured the impact of a continuing medical education-accredited provider training intervention on provider attitudes, knowledge, and practices in a cluster randomized trial in 40 US health centers from 2011 through 2013. Twenty clinics were randomly assigned to the intervention arm; 20 offered routine care. Clinic staff participated in baseline and 1-year surveys assessing intrauterine device and implant knowledge, attitudes, and practices. We used a difference-in-differences approach to compare changes that occurred in the intervention sites to changes in the control sites 1 year later. Prespecified outcome measures included: knowledge of patient eligibility for intrauterine devices and implants; attitudes about method safety; and counseling practices. We used multivariable regression with generalized estimating equations to account for clustering by clinic to examine intervention effects on provider outcomes 1 year later. RESULTS: Overall, we surveyed 576 clinic staff (314 intervention, 262 control) at baseline and/or 1-year follow-up. The change in proportion of providers who believed that the intrauterine device was safe was greater in intervention (60% at baseline to 76% at follow-up) than control sites (66% at both times) (adjusted odds ratio, 2.48; 95% confidence interval, 1.13-5.4). Likewise, for the implant, the proportion increased from 57-77% in intervention, compared to 61-65% in control sites (adjusted odds ratio, 2.57; 95% confidence interval, 1.44-4.59). The proportion of providers who believed they were experienced to counsel on intrauterine devices also increased in intervention (53-67%) and remained the same in control sites (60%) (adjusted odds ratio, 1.89; 95% confidence interval, 1.04-3.44), and for the implant increased more in intervention (41-62%) compared to control sites (48-50%) (adjusted odds ratio, 2.30; 95% confidence interval, 1.28-4.12). Knowledge scores of patient eligibility for intrauterine devices increased at intervention sites (from 0.77-0.86) 6% more over time compared to control sites (from 0.78-0.80) (adjusted coefficient, 0.058; 95% confidence interval, 0.003-0.113). Knowledge scores of eligibility for intrauterine device and implant use with common medical conditions increased 15% more in intervention (0.65-0.79) compared to control sites (0.67-0.66) (adjusted coefficient, 0.15; 95% confidence interval, 0.09-0.21). Routine discussion of intrauterine devices and implants by providers in intervention sites increased significantly, 71-87%, compared to in control sites, 76-82% (adjusted odds ratio, 1.97; 95% confidence interval, 1.02-3.80). CONCLUSION: Professional guidelines encourage intrauterine device and implant competency for all contraceptive care providers. Integrating these methods into routine care is important for access. This replicable training intervention translating evidence into care had a sustained impact on provider attitudes, knowledge, and counseling practices, demonstrating significant changes in clinical care a full year after the training intervention.

Contraception after medication abortion in the United States: results from a cluster randomized trial.

BACKGROUND: Understanding how contraceptive choices and access differ for women having medication abortions compared to aspiration procedures can help to identify priorities for improved patient-centered postabortion contraceptive care. OBJECTIVE: The objective of this study was to investigate the differences in contraceptive counseling, method choices, and use between medication and aspiration abortion patients. STUDY DESIGN: This subanalysis examines data from 643 abortion patients from 17 reproductive health centers in a cluster, randomized trial across the United States. We recruited participants aged 18-25 years who did not desire pregnancy and followed them for 1 year. We measured the effect of a full-staff contraceptive training and abortion type on contraceptive counseling, choice, and use with multivariable regression models, using generalized estimating equations for clustering. We used survival analysis with shared frailty to model actual intrauterine device and subdermal implant initiation over 1 year. RESULTS: Overall, 26% of participants (n = 166) had a medication abortion and 74% (n = 477) had an aspiration abortion at the enrollment visit. Women obtaining medication abortions were as likely as those having aspiration abortions to receive counseling on intrauterine devices or the implant (55%) and on a short-acting hormonal method (79%). The proportions of women choosing to use these methods (29% intrauterine device or implant, 58% short-acting hormonal) were also similar by abortion type. The proportions of women who actually used short-acting hormonal methods (71% medication vs 57% aspiration) and condoms or no method (20% vs 22%) within 3 months were not significantly different by abortion type. However, intrauterine device initiation over a year was significantly lower after the medication than the aspiration abortion (11 per 100 person-years vs 20 per 100 person-years, adjusted hazard ratio, 0.50; 95% confidence interval, 0.28-0.89). Implant initiation rates were low and similar by abortion type (5 per 100 person-years vs 4 per 100 person-years, adjusted hazard ratio, 2.41; 95% confidence interval, 0.88-6.59). In contrast to women choosing short-acting methods, relatively few of those choosing a long-acting method at enrollment, 34% of medication abortion patients and 53% of aspiration abortion patients, had one placed within 3 months. Neither differences in health insurance nor pelvic examination preferences by abortion type accounted for lower intrauterine device use among medication abortion patients. CONCLUSION: Despite similar contraceptive choices, fewer patients receiving medication abortion than aspiration abortion initiated intrauterine devices over 1 year of follow-up. Interventions to help patients receiving medication abortion to successfully return for intrauterine device placement are warranted. New protocols for same-day implant placement may also help patients receiving medication abortion and desiring a long-acting method to receive one.

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

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

Reductions in pregnancy rates in the USA with long-acting reversible contraception: a cluster randomised trial.

BACKGROUND: Unintended pregnancy remains a serious public health challenge in the USA. We assessed the effects of an intervention to increase patients' access to long-acting reversible contraceptives (LARCs) on pregnancy rates. METHODS: We did a cluster randomised trial in 40 reproductive health clinics across the USA in 2011-13. 20 clinics were randomly assigned to receive evidence-based training on providing counselling and insertion of intrauterine devices (IUDs) or progestin implants and 20 to provide standard care. Usual costs for contraception were maintained at all sites. We recruited women aged 18-25 years attending family planning or abortion care visits and not desiring pregnancy in the next 12 months. The primary outcome was selection of an IUD or implant at the clinic visit and secondary outcome was pregnancy within 12 months. We used generalised estimating equations for clustered data to measure the intervention effect on contraceptive selection, and used survival analysis to assess pregnancy rates. FINDINGS: Of 1500 women enrolled, more at intervention than control sites reported receiving counselling on IUDs or implants (565 [71%] of 797 vs 271 [39%] of 693, odds ratio 3·8, 95% CI 2·8-5·2) and more selected LARCs during the clinic visit (224 [28%] vs 117 [17%], 1·9, 1·3-2·8). The pregnancy rate was lower in intervention group than in the control group after family planning visits (7·9 vs 15·4 per 100 person-years), but not after abortion visits (26·5 vs 22·3 per 100 person-years). We found a significant intervention effect on pregnancy rates in women attending family planning visits (hazard ratio 0·54, 95% CI 0·34-0·85). INTERPRETATION: The pregnancy rate can be reduced by provision of counselling on long-term reversible contraception and access to devices during family planning counselling visits. FUNDING: William and Flora Hewlett Foundation.

Funding policies and postabortion long-acting reversible contraception: results from a cluster randomized trial.

BACKGROUND: Almost one-half of women having an abortion in the United States have had a previous procedure, which highlights a failure to provide adequate preventive care. Provision of intrauterine devices and implants, which have high upfront costs, can be uniquely challenging in the abortion care setting. OBJECTIVE: We conducted a study of a clinic-wide training intervention on long-acting reversible contraception and examined the effect of the intervention, insurance coverage, and funding policies on the use of long-acting contraceptives after an abortion. STUDY DESIGN: This subanalysis of a cluster, randomized trial examines data from the 648 patients who had undergone an abortion who were recruited from 17 reproductive health centers across the United States. The trial followed participants 18-25 years old who did not desire pregnancy for a year. We measured the effect of the intervention, health insurance, and funding policies on contraceptive outcomes, which included intrauterine device and implant counseling and selection at the abortion visit, with the use of logistic regression with generalized estimating equations for clustering. We used survival analysis to model the actual initiation of these methods over 1 year. RESULTS: Women who obtained abortion care at intervention sites were more likely to report intrauterine device and implant counseling (70% vs 41%; adjusted odds ratio, 3.83; 95% confidence interval, 2.37-6.19) and the selection of these methods (36% vs 21%; adjusted odds ratio, 2.11; 95% confidence interval, 1.39-3.21). However, the actual initiation of methods was similar between study arms (22/100 woman-years each; adjusted hazard ratio, 0.88; 95% confidence interval, 0.51-1.51). Health insurance and funding policies were important for the initiation of intrauterine devices and implants. Compared with uninsured women, those women with public health insurance had a far higher initiation rate (adjusted hazard ratio, 2.18; 95% confidence interval, 1.31-3.62). Women at sites that provide state Medicaid enrollees abortion coverage also had a higher initiation rate (adjusted hazard ratio, 1.73; 95% confidence interval, 1.04-2.88), as did those at sites with state mandates for private health insurance to cover contraception (adjusted hazard ratio, 1.80; 95% confidence interval, 1.06-3.07). Few of the women with private insurance used it to pay for the abortion (28%), but those who did initiated long-acting contraceptive methods at almost twice the rate as women who paid for it themselves or with donated funds (adjusted hazard ratio, 1.94; 95% confidence interval, 1.10-3.43). CONCLUSIONS: The clinic-wide training increased long-acting reversible contraceptive counseling and selection but did not change initiation for abortion patients. Long-acting method use after abortion was associated strongly with funding. Restrictions on the coverage of abortion and contraceptives in abortion settings prevent the initiation of desired long-acting methods.

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

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

Does Integrating Family Planning into HIV Services Improve Gender Equitable Attitudes? Results from a Cluster Randomized Trial in Nyanza, Kenya.

This study investigated whether integrating family planning (FP) services into HIV care was associated with gender equitable attitudes among HIV-positive adults in western Kenya. Surveys were conducted with 480 women and 480 men obtaining HIV services from 18 clinics 1 year after the sites were randomized to integrated FP/HIV services (N = 12) or standard referral for FP (N = 6). We used multivariable regression, with generalized estimating equations to account for clustering, to assess whether gender attitudes (range 0-12) were associated with integrated care and with contraceptive use. Men at intervention sites had stronger gender equitable attitudes than those at control sites (adjusted mean difference in scores = 0.89, 95 % CI 0.03-1.74). Among women, attitudes did not differ by study arm. Gender equitable attitudes were not associated with contraceptive use among men (AOR = 1.06, 95 % CI 0.93-1.21) or women (AOR = 1.03, 95 % CI 0.94-1.13). Further work is needed to understand how integrating FP into HIV care affects gender relations, and how improved gender equity among men might be leveraged to improve contraceptive use and other reproductive health outcomes.

Service provider perspectives on post-abortion contraception in Nepal.

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

Risk of violence from the man involved in the pregnancy after receiving or being denied an abortion.

BACKGROUND: Intimate partner violence is common among women having abortions, with between 6% and 22% reporting recent violence from an intimate partner. Concern about violence is a reason some pregnant women decide to terminate their pregnancies. Whether risk of violence decreases after having an abortion, remains unknown. METHODS: Data are from the Turnaway Study, a prospective cohort study of women seeking abortions at 30 facilities across the U.S. Participants included women who: presented just prior to a facility's gestational age limit and received abortions (Near Limit Abortion Group, n = 452), presented just beyond the gestational limit and were denied abortions (Turnaways, n = 231), and received first trimester abortions (First Trimester Abortion Group, n = 273). Mixed effects logistic regression was used to assess the relationship between receiving versus being denied abortion and subsequent violence from the man involved in the pregnancy over 2.5 years. RESULTS: Physical violence decreased for Near Limits (adjusted odds ratios (aOR), 0.93 per month; 95% Confidence Interval (CI) 0.90, 0.96), but not Turnaways who gave birth (P < .05 versus Near Limits). The decrease for First Trimesters was similar to Near Limits (P = .324). Psychological violence decreased for all groups (aOR, 0.97; CI 0.94, 1.00), with no differential change across groups. CONCLUSIONS: Policies restricting abortion provision may result in more women being unable to terminate unwanted pregnancies, potentially keeping them in contact with violent partners, and putting women and their children at risk.

Perceived stress and emotional social support among women who are denied or receive abortions in the United States: a prospective cohort study.

BACKGROUND: Examining women's stress and social support following denial and receipt of abortion furthers understanding of the effects of unwanted childbearing and abortion on women's well-being. This study investigated perceived stress and emotional social support over time among women who were denied wanted abortions and who received abortions, and compared outcomes between the groups. METHODS: The Turnaway Study is a prospective cohort study of women who sought abortions at 30 abortion facilities across the United States, and follows women via semiannual phone interviews for five years. Participants include 956 English or Spanish speaking women aged 15 and over who sought abortions between 2008 and 2010 and whose gestation in pregnancy fit one of three groups: women who presented up to three weeks beyond a facility's gestational age limit and were denied an abortion; women presenting within two weeks below the limit who received an abortion; and women who received a first trimester abortion. The outcomes were modified versions of the Perceived Stress Scale and the Multidimensional Scale of Perceived Social Support. Longitudinal mixed effects models were used to assess differences in outcomes between study groups over 30 months. RESULTS: Women denied abortions initially had higher perceived stress than women receiving abortions near gestational age limits (1.0 unit difference on 0-16 scale, P = 0.003). Women receiving first-trimester abortions initially had lower perceived stress than women receiving abortions near gestational age limits (0.6 difference, P = 0.045). By six months, all groups' levels of perceived stress were similar, and levels remained similar through 30 months. Emotional social support scores did not differ among women receiving abortions near gestational limits versus women denied abortions or women having first trimester abortions initially or over time. CONCLUSIONS: Soon after being denied abortions, women experienced higher perceived stress than women who received abortions. The study found no longer-term differences in perceived stress or emotional social support between women who received versus were denied abortions.

Is legal recreational cannabis associated with cannabis use during pregnancy, beliefs about safety, and perceived community stigma?

BACKGROUND: Among pregnant and recently pregnant people we investigated whether legal recreational cannabis is associated with pregnancy-related cannabis use, safety beliefs, and perceived community stigma. METHODS: In 2022, we surveyed 3571 currently and recently pregnant English- or Spanish-speaking adults in 37 states. Primary outcomes included cannabis use during pregnancy and two continuous scale measures of beliefs about safety and perceived community stigma. Using generalized linear models and mixed effects ordinal logistic regression with random effects for state, we assessed associations between legal recreational cannabis and outcomes of interest, controlling for state-level and individual-level covariates and specifying appropriate functional form. RESULTS: Those who reported cannabis use during pregnancy were more likely to believe it is safe and to perceive community stigma compared to those who did not report use during pregnancy. Legal recreational cannabis was not associated with cannabis use during pregnancy, continuation or increase in use, frequency of use, or safety beliefs. Legal recreational cannabis was associated with lower perceived community stigma (coefficient: -0.07, 95% CI: -0.13, -0.01), including among those who reported use during (coefficient = -0.22, 95% CI: -0.40, -0.04) and prior to but not during (coefficient = -0.19, 95% CI: -0.37, -0.01) pregnancy. CONCLUSION: Findings do not support concerns that legal recreational cannabis is associated with cannabis use during pregnancy or beliefs about safety. Legal recreational cannabis may be associated with lower community stigma around cannabis use during pregnancy, which could have implications for pregnant people's disclosure of use and care-seeking behavior.