Medical management of early pregnancy loss with mifepristone and misoprostol in emergency departments compared to a Complex Family Planning office: Implementation of a COVID-19 institutional policy change.

OBJECTIVES: To evaluate the implementation of mifepristone and misoprostol for medical management of early pregnancy loss (EPL) in emergency departments (EDs) by comparing efficacy, complication, and follow-up rates for patients treated in EDs to the Complex Family Planning (CFP) outpatient office. STUDY DESIGN: In COVID-19's first wave, we expanded medical management of EPL to our EDs. This retrospective study evaluated 72 patients receiving mifepristone and misoprostol for EPL from April 1, 2020 to March 31, 2021, comparing treatment success, safety outcomes, and follow-up rates by location. RESULTS: Thirty-three (46%) patients received care in the ED and 39 (54%) at CFP. Treatment success was lower in EDs (23, 70%) compared to CFP (34, 87%), but after adjusting for insurance status and pregnancy type (miscarriage, uncertain viability, unknown location), this was not significant: adjusted odds ratio 0.48 (95% CI 0.13-1.81). More ED patients underwent emergent interventions (3 vs 0) including two emergent uterine aspirations, one uterine artery embolization, and two blood transfusions. Two cases were attributed to misdiagnosis (cesarean scar and cervical ectopic pregnancies interpreted as incomplete miscarriages) and one to guideline nonadherence. No complications occurred in the CFP group. Follow-up rates were over 80% in both groups. More ED patients engaged in telehealth follow-up (67% vs 18%, p ≤ 0.0001). CONCLUSIONS: In this small sample, we observed a trend toward less successful treatment in the ED compared to the CFP office. Both correctly making uncommon diagnoses and adhering to new guidelines presented implementation challenges. IMPLICATIONS: Implementing mifepristone and misoprostol for EPL in our EDs achieved lower rates of pregnancy resolution compared to outpatient management. Complex uncommon diagnoses and implementing new care pathways in EDs may have contributed to complications and highlighted opportunities for improvement. Additional studies are needed to further quantify safety outcomes for EPL management in EDs.

Outcomes for Women Denied Postpartum Tubal Ligation During the Initial COVID-19 Surge.

Objective: To evaluate the utilization and outcomes of postpartum long-acting reversible contraception (PPLARC) following unmet postpartum bilateral tubal ligation (PPBTL) requests during a time in which elective surgeries were canceled due to the initial COVID-19 surge. Methods: We conducted a mixed-methods study using an embedded design. Using a retrospective cohort design, we collected data from patients seeking PPBTL following vaginal delivery between March 15, 2020, and June 20, 2020; this reflects a time period during which elective surgery was canceled thus making PPBTL unavailable. We recorded demographic data, method of contraception at time of discharge and 18 months postpartum, and incidence of interval pregnancy at 18 months postpartum. Additionally, we conducted five semistructured interviews to gain deeper insights into patient experiences with PPLARC as a bridge method. Results: Forty-five patients had unfilled PPBTL requests with follow-up data available for 35. The median age was 34 years. Ten (22%) accepted PPLARC as a bridge to interval bilateral tubal ligation (BTL). At the 18-month mark, only 1 out of 7 (14.3%) PPLARC users had undergone an interval BTL procedure, compared to 11 out of 28 (39.3%) nonusers. None of the PPLARC users experienced pregnancies, while 6 out of 28 (21.6%) nonusers became pregnant. Qualitative interviews underscored themes such as inadequate counseling preparation for unmet PPBTL requests and persistent barriers to BTL access. Conclusions: Raising awareness of unmet PPBTL risks may drive greater adoption of PPLARC as a bridge method. While not a substitution for PPTBL, PPLARC provides a reliable form of interval contraception for patients seeking to delay pregnancy. It is essential to recognize that patient security with PPLARC's contraceptive efficacy may introduce delays in achieving the desired interval sterilization. Enhancing antenatal counseling on contraception options and providing transparency regarding barriers to sterilization could mitigate the challenges associated with unmet PPBTL requests.

Institutional leadership after Dobbs: a mixed methods analysis of US medical schools' public statements regarding abortion.

INTRODUCTION: Medical schools, as significant and influential organisations within their communities, have the potential and the capacity to impact abortion policy. Organisations often engage in advocacy by issuing public statements that clarify their stance on specific policies. This study analyses the quantity and quality of publicly discoverable statements that US medical schools issued regarding Dobbs v Jackson Women's Health Organization. METHODS: We conducted a mixed methods study using an explanatory sequential design. Using qualitative analysis, an inductive thematic approach was used to identify themes from public statements made within 6 months of 2 May 2022, Dobbs leak. Descriptive statistics and logistic regression analysis were used to assess the association between themes and institutional characteristics. RESULTS: Most institutions (n=124/188, 65.96%) did not issue public statements regarding Dobbs. Among all 188 US medical schools, allopathic institutions (OR=12.19, 95% CI (2.83 to 52.57), p=0.001), schools in protective states (OR=3.35, 95% CI (1.78 to 6.29), p<0.0001) and those with family planning divisions (OR=4.60, 95% CI (2.33 to 9.08), p<0.0001) were at increased odds of issuing statements. Of the 64 medical schools with statements, 64.06% (n=41/64) espoused pro-choice views, 34.37% (n=22) were neutral/non-committal and 1.56% (n=1) expressed antiabortion views. Those in protective states were at 3.35 times increased odds of issuing pro-choice statements (95% CI (1.16 to 9.72), p=0.03) compared with restrictive counterparts. CONCLUSION: Medical schools largely did not take a public stance on Dobbs. By refraining from actively engaging in this critical discourse, medical schools are foregoing a leadership opportunity to affect meaningful sociopolitical change, particularly in states with restrictive abortion laws.

Shortcomings and disparities in contraception counseling and use by hypertensive individuals at risk for unintended pregnancy: a comparative analysis of the National Survey of Family Growth.

BACKGROUND: Hypertension is a leading cause of adverse pregnancy outcomes. These outcomes disproportionately affect Black individuals. Reproductive life planning that includes patient-centered contraception counseling could mitigate the impact of unintended pregnancy. OBJECTIVE: The primary objective of the study is to compare contraception counseling and use between hypertensive and nonhypertensive individuals at risk for unintended pregnancy. Our secondary objectives are the following: (1) to evaluate the effect of race on the probability of counseling and the use of contraception, and (2) to evaluate the methods used by individuals with hypertension. METHODS: Data from the 2015-2017 and 2017-2019 National Survey of Family Growth Female Respondent Files were used to analyze whether individuals who reported being informed of having high blood pressure within the previous 12 months received counseling about contraception or received a contraceptive method. Covariates considered in the analysis included age, race, parity, educational attainment, body mass index, smoking, diabetes, and experience with social determinants of health. The social determinants of health covariate was based on reported experiences within 5 social determinants of health domains: food security, housing stability, financial security, transportation access, and childcare needs. Linear probability models were used to estimate the adjusted probability of receiving counseling and the use of a contraceptive. Using difference-in-difference analyses, we compared the change in counseling and use between hypertensive and nonhypertensive respondents by race, relative to White respondents. RESULTS: Of the 8625 participants analyzed, 771 (9%) were hypertensive. Contraception counseling was received by 26.2% (95% confidence interval, 20.4-31.9) of hypertensive individuals and 20.7% (95% confidence interval, 19.3-22.2) of nonhypertensive individuals. Contraception use was reported by 39.8% (95% confidence interval, 33.2-46.5) of hypertensive and 35.3% (95% confidence interval, 33.3-37.2) of nonhypertensive individuals. The linear probability model adjusting for age, parity, education attainment, body mass index, smoking, diabetes, and social determinants of health indicated that hypertensive individuals were 8 percentage points (95% confidence interval, 3-18 percentage points) more likely to receive counseling and 9 percentage points (95% confidence interval, 3-16 percentage points) more likely to use contraception. Hypertensive Black individuals did not receive more counseling or use more contraceptives compared with nonhypertensive Black individuals. The difference in counseling when hypertension was present was 13 percentage points lower than the difference observed for White respondents when hypertension was present (P=.01). The most frequently used contraceptive method among hypertensive individuals was combined oral contraceptive pills (54.0%; 95% confidence interval, 44.3%-63.5%). CONCLUSION: Despite the higher likelihood of receiving contraception counseling and using contraception among hypertensive individuals at risk for unintended pregnancy, two-thirds of this population did not receive contraception counseling, and <40% used any contraceptive method. Furthermore, unlike White individuals, Black individuals with hypertension did not receive more contraception care than nonhypertensive Black individuals. Of all those who used contraception, half relied on a method classified as Centers for Disease Control and Prevention Medical Eligibility Criteria Category 3. These findings highlight a substantial unmet need for safe and accessible contraception options for hypertensive individuals at risk for unintended pregnancy, emphasizing the importance of targeted interventions to improve contraceptive care and counseling in this population.

Reproductive Justice as a Framework for Abortion Care.

This article presents an in-depth analysis of abortion access and rights within the Reproductive Justice framework, underscoring the health, social, and economic consequences of limited access. It emphasizes the critical role of abortion as essential, safe health care and highlights the complexities surrounding abortion decisions and the barriers faced by poor and historically marginalized populations. Amid the escalating access restrictions, the article concludes with a call to action for obstetricians and gynecologists and our allied health care providers to recognize, support, and advocate for safe, legal, and affordable abortion services as fundamental to health care equity and human rights.

Women Trust Their OBGYNs to Provide Preexposure Prophylaxis: An Opportunity for HIV Prevention.

Objective: The objective of this study was to understand how women perceive the role of their Obstetrician and Gynecologist (OBGYN) in screening for and providing preexposure prophylaxis (PrEP) for HIV prevention. Methods: We recruited women ages 18-45 years receiving obstetric or gynecological care at an academic medical center in the Bronx, NY. Thirty participants were enrolled: 10 seeking care for family planning, 10 seeking prenatal care, and 10 seeking care for a sexually transmitted infection. We screened participants for HIV acquisition risk using a PrEP screening tool. We conducted face-to-face, semi-structured interviews, which were audio-recorded, transcribed, and entered into Dedoose for analysis of themes using a grounded theory approach. Results: Sixty percent of the participants were Latinx and 33% African American. Seventy percent had one or more risk factors for HIV acquisition based on the PrEP screening tool, indicating they would benefit from a PrEP discussion. Three main themes emerged from the analysis of interview data. Participants viewed OBGYNs as experts in sexual and reproductive healthcare and believed they were experts in PrEP. Participants were concerned about "PrEP stigma", being judged by their clinicians as being sexually promiscuous if they expressed a need for PrEP. Lastly, when participants trusted their OBGYN, that trust became a facilitator for women to consider PrEP and offset stigma as a barrier to identifying patients who are candidates for PrEP. Conclusion: Women established in care with an OBGYN are enthusiastic about having access to PrEP services incorporated into their sexual and reproductive healthcare. A universal approach to HIV prevention would avert stigma surrounding HIV care and prevention.

"Being able to do whatever you wanna do as a woman is important:" a qualitative exploration of contraception as a frame of reference for HIV prevention with PrEP.

BACKGROUND: Use of HIV PrEP (pre-exposure prophylaxis) is a strategic tool in the effort to end the HIV epidemic. 20% of new HIV infections in the US are among cis-gender women, yet they comprise only 5% of all PrEP users. Black women disproportionately bear the burden of new HIV acquisition and accounted for almost 60% of new HIV diagnoses among women in 2018. Increasing understanding and uptake of PrEP among women at risk of HIV acquisition in alignment with their reproductive values and preferences is key to increasing PrEP uptake and decreasing HIV burden in this population. OBJECTIVE: This study examines how experiences with contraception among women of color shape their perceptions and preferences regarding HIV PrEP to inform counseling that aligns with their reproductive values. METHODS: Women aged 18-45 who self-identified as Black or Latina were recruited at an academic medical center in the Bronx from June 2018 to July 2019. We enrolled 30 participants seeking family planning care (10), prenatal care (10), or care for sexually transmitted infections (10). Participants completed a brief written survey assessing their risk of HIV acquisition. Semi-structured, face-to-face interviews were then audio-recorded, transcribed, and entered into Dedoose. Grounded theory and constant comparison approaches were used to analyze the data. RESULTS: Twenty-one participants (70%) screened positive for HIV acquisition risk. Four had received information on PrEP from a medical provider prior to the interview. Three themes emerged from the qualitative analysis: (1) Similar to oral contraception, women conceptualized PrEP as a "daily pill" to support their reproductive health; (2) Women perceived PrEP as a tool to support autonomy and pleasure in their sexual health; (3) Like birth control, women desired multiple delivery options for HIV prophylaxis. CONCLUSIONS: Contraception may serve as a frame of reference when counseling about PrEP among cis-women at risk of acquiring HIV. Our study suggests that this approach re-contextualizes counseling on PrEP within a sex-positive framework that prioritizes pleasure, safety, and autonomy as integral to sexual and reproductive wellness. Consideration of historically marginalized women's experiences with contraception and reproductive values may facilitate their use of PrEP.

PrEP (pre-exposure prophylaxis) is a medicine taken daily by people at risk of getting HIV from sex or injection drug use. Although PrEP is a safe and effective medication for women, the use of PrEP remains exceedingly low among cis-gender women at risk of HIV in the US. This study examines how experiences with contraception among women of color, who disproportionately bear the burden of HIV acquisition, shape their perceptions and preferences regarding PrEP. We interviewed 30 women who self-identified as Black or Latina at an academic medical center in the Bronx. Similar to oral contraception, women in this study conceptualized PrEP as a "daily pill" to support their reproductive health. This report details how women's experiences with contraception may serve as the foundation to re-contextualize conversations on PrEP within a sex-positive framework that prioritizes pleasure, safety, and autonomy as integral to sexual and reproductive wellness.

Risk of Sterilization Regret and Age: An Analysis of the National Survey of Family Growth, 2015-2019.

OBJECTIVE: To estimate the risk of sterilization regret based on age at the time of sterilization in a contemporary group of women. METHODS: We conducted a retrospective analysis of cross-sectional data from the 2015-2017 and 2017-2019 National Survey of Family Growth, Female Respondent Files, to estimate the proportion of women who experience sterilization regret. Descriptive statistics were used to describe the population and the proportion with regret. Sterilization regret was defined as someone who either underwent sterilization reversal or who definitely wanted sterilization reversal. Multivariable logistic regression models were used to assess associations with sterilization regret. RESULTS: A total of 1,549 women who underwent sterilization were included in the analysis; 8% were aged 21-30 years, and 92% were aged older than 30 years. Of the participants, 16.9% identified as Black, 22.0% as Hispanic, and 57.2% as White. Most (58.4%) underwent a tubal sterilization procedure between age 21 and 30 years. The cumulative proportion of regret was 10.2% (12.6% for women who underwent sterilization at age 21-30 years and 6.7% for those who underwent sterilization at older than age 30 years). After controlling for covariates including age, race, parity, educational attainment, and medical reason for sterilization, the only variable that had a statistically significant association with regret was age at the time of the interview (P<.001). As women got older, they were less likely to report sterilization regret. CONCLUSION: Younger women experience more sterilization regret. As women get older, sterilization regret decreases. Counseling about sterilization should reveal the unpredictability of future desire, but age alone must not be a barrier to performing sterilization.

Educational behaviors of pregnant women in the Bronx during Zika's International emerging epidemic: "First mom and then I'd Google. And then my doctor".

BACKGROUND: The objective of the study was to understand how pregnant women learned about Zika infection and to identify what sources of information were likely to influence them during their pregnancy. METHODS: We conducted 13 semi-structed interviews in English and Spanish with women receiving prenatal care who were tested for Zika virus infection. We analyzed the qualitative data using descriptive approach. RESULTS: Pregnant women in the Bronx learned about Zika from family, television, the internet and their doctor. Informational sources played different roles. Television, specifically Spanish language networks, was often the initial source of information. Women searched the internet for additional information about Zika. Later, they engaged in further discussions with their healthcare providers. CONCLUSIONS: Television played an important role in providing awareness about Zika to pregnant women in the Bronx, but that information was incomplete. The internet and healthcare providers were sources of more complete information and are likely the most influential. Efforts to educate pregnant women about emerging infectious diseases will benefit from using a variety of approaches including television messages that promote public awareness followed up by reliable information via the internet and healthcare providers.

Auricular acupuncture as an adjunct for pain management during first trimester abortion: a randomized, double-blinded, three arm trial.

OBJECTIVES: To assess pain-management using auricular acupuncture as an adjunct to ibuprofen and paracervical block during first trimester uterine aspiration, and to assess auricular acupuncture's effect on anxiety. STUDY DESIGN: This randomized, double-blinded, three-arm trial enrolled women undergoing uterine aspiration for spontaneous or induced abortion. Study participants were randomized 1:1:1 to receive auricular acupuncture, placebo, or usual care alone. Participants in all groups received ibuprofen and paracervical block (usual care). The main outcome was maximum pain reported at the end of the procedure measured using a Visual Analog Scale; we compared those receiving auricular acupuncture to those receiving usual care alone. We also compared auricular acupuncture to placebo and placebo to usual care alone. Finally, we compared the maximum anxiety scores between participants randomized to auricular acupuncture, placebo, and usual care alone. RESULTS: We randomized 153 women over 9 months, and analyzed 52 participants in the auricular acupuncture group, 49 in the placebo group, and 49 in the usual care group. The groups had similar baseline characteristics. After uterine aspiration, participants reported median maximum pain scores as follows: auricular acupuncture 39.5 (interquartile range (IQR) 11, 64.5), placebo 70.0 (IQR 40.5, 84), and usual care alone 71.0 (IQR 32, 91.5) (p<0.01). In pairwise comparisons, the median maximum pain score after auricular acupuncture was lower than placebo and usual-care groups (p<0.01 for both). Post-procedure median anxiety scores were 11.5, 31.0 and 44.0, respectively (p=.01). CONCLUSIONS: Women undergoing first trimester uterine aspiration assigned to auricular acupuncture reported substantially less pain and anxiety than women assigned to placebo or usual care. IMPLICATIONS: Auricular acupuncture may be a useful adjunct to ibuprofen and paracervical block during first trimester uterine aspiration. This approach to managing pain and anxiety could avoid the operational complexities and expenses of sedation and opioid use.

Etonogestrel-Releasing Contraceptive Implant for Postpartum Adolescents: A Randomized Controlled Trial.

STUDY OBJECTIVE: To compare immediate postpartum insertion of the contraceptive implant to placement at the 6-week postpartum visit among adolescent and young women. DESIGN: Non-blinded, randomized controlled trial. SETTING AND PARTICIPANTS: Postpartum adolescents and young women ages 14-24 years who delivered at an academic tertiary care hospital serving rural and urban populations in North Carolina. INTERVENTIONS: Placement of an etonogestrel-releasing contraceptive implant before leaving the hospital postpartum, or at the 4-6 week postpartum visit. MAIN OUTCOME MEASURES: Contraceptive implant use at 12 months postpartum. RESULTS: Ninety-six participants were randomized into the trial. Data regarding use at 12 months were available for 64 participants, 37 in the immediate group and 27 in the 6-week group. There was no difference in use at 12 months between the immediate group and the 6-week group (30 of 37, 81% vs 21 of 27, 78%; P = .75). At 3 months, the immediate group was more likely to have the implant in place (34 of 37, 92% vs 19 of 27, 70%; P = .02). CONCLUSION: Placing the contraceptive implant in the immediate postpartum period results in a higher rate of use at 3 months postpartum and appears to have similar use rates at 12 months compared with 6-week postpartum placement. Providing contraceptive implants to adolescents before hospital discharge takes advantage of access to care, increases the likelihood of effective contraception in the early postpartum period, appears to have no adverse effects on breastfeeding, and might lead to increased utilization at 1 year postpartum.

A randomized trial of levonorgestrel intrauterine system insertion 6 to 48 h compared to 6 weeks after vaginal delivery; lessons learned.

The objective of this randomized trial was to compare breastfeeding among women who received a levonorgestrel-releasing intrauterine system within 6-48 h (early) or 4-6 weeks (standard) after an uncomplicated vaginal birth. Analysis groups of 86 women in each arm were needed to demonstrate a 20% difference in any breastfeeding. Thirty-five women were randomized to the early (N=17) and standard (N=18) arms. The combination of unsuccessful placement (2/17; 12%), expulsions (7/17; 41%) and removals (3/17; 18%) reached 71% (12/17) in the early arm, so the study was stopped. In our small study cohort, levonorgestrel-releasing intrauterine system insertion between 6 and 48 h after vaginal birth was associated with a high rate of expulsion or removal soon after insertion.