Primary Care's Role in Prescribing Mail-Order Mifepristone.

This Viewpoint discusses the controversy over mail-order mifepristone prescribed by primary care clinicians for first-trimester abortion as it relates to the history of initial approval, the Supreme Court case Alliance for Hippocratic Medicine v US Food and Drug Administration, and available clinical research.

Patient experiences using public and private insurance coverage for abortion in Illinois: Implementation successes and remaining gaps.

CONTEXT: Insurance coverage for abortion in states where care remains legal can alleviate financial burdens for patients and increase access. Recent policy changes in Illinois required Medicaid and some private insurance plans to cover abortion care. This study explores policy implementation from the perspectives of patients using their insurance to obtain early abortion care. METHODOLOGY: Between July 2021 and February 2022, we interviewed Illinois residents who recently sought abortion care at ≤11 weeks of pregnancy. We also interviewed nine key informants with experience providing or billing for abortion or supporting insurance policy implementation in Illinois. We coded interview transcripts in Dedoose and developed code summaries to identify salient themes across interviews. RESULTS: Most participants insured by Illinois Medicaid or eligible for enrollment received full coverage for their abortions; most with private insurance did not and faced challenges learning about coverage status. Some opted not to use insurance, often citing privacy concerns. Participants who benefited from abortion coverage expressed relief, gave examples of other financial challenges they could prioritize, and described feeling in control of their abortion experience. Those without coverage described feeling stressed, uncertain, and constrained in their decision-making. CONCLUSION: When abortion was fully covered by insurance, it reduced financial burdens and enhanced reproductive autonomy. Illinois Medicaid policy-with seamless enrollment options and appropriate reimbursement rates-offers a model for improving abortion access in other states. Further investigation is needed to determine compliance among private insurance companies and increase transparency.

Departmental Metrics to Guide Equity, Diversity, and Inclusion for Academic Family Medicine Departments.

PROBLEM: Equity, diversity, and inclusion (EDI) efforts have accelerated over the past several years, without a traditional guidebook that other missions often have. To evaluate progress over time, departments of family medicine are seeking ways to measure their current EDI state. Across the specialty, unity regarding which EDI metrics are meaningful is absent, and discordance even exists about what should be measured. APPROACH: This paper provides a general metrics framework, including a wide array of possibilities to consider measuring, for assessing individual departmental progress in this broad space. These measures are designed to be general enough to provide common language and can be customized to align with strategic priorities of individual family medicine departments. OUTCOMES: The Diversity, Equity, and Inclusion Committee of the Association of Departments of Family Medicine has produced a common framework to facilitate measurement of EDI outcomes in the following areas: care delivery and health, workforce recruitment and retention, learner recruitment and training, and research participation. This framework allows departments to monitor progress across these domains that impact the tripartite mission, providing opportunities to capitalize on measured gains in EDI. NEXT STEPS: Departments can review this framework and consider which metrics are applicable or develop their own metrics to align with their strategic priorities. In the future, collective departments could compare notes and measure aggregate progress together. Evaluating progress is a step in the journey toward the goal of ensuring that departments are operating from inclusive and just academic systems.

Mifepristone implementation in primary care: Clinician and staff insights from a pilot learning collaborative.

OBJECTIVES: The ExPAND Mifepristone (ExPAND) learning collaborative aims to support primary care providers in overcoming logistical barriers to mifepristone provision. This qualitative study describes clinician and staff perspectives on the impact of ExPAND in two federally qualified health center networks (FQHCs). STUDY DESIGN: Researchers conducted semi-structured qualitative interview with a purposive sample of clinicians, staff, and leadership from two Illinois FQHCs. We analyzed transcripts in batches using modified grounded theory to identify themes regarding the reception of ExPAND and barriers to and facilitators of mifepristone implementation. RESULTS: Participants (n = 13) expressed strong support for providing mifepristone for miscarriage management at their clinics. Most also personally supported mifepristone for abortion care. Many participants felt that ExPAND reflected their clinics' values, as it strengthens the primary care relationship, emphasizes patient-centered care, and addresses disparities in access. Barriers to implementation included fear that providing abortion care would jeopardize FQHC funding and logistical hurdles due to the coronavirus disease pandemic. CONCLUSIONS: Participants felt that mifepristone provision in primary care was an important service, and that ExPAND helped achieve that goal. Future clinics participating in ExPAND would benefit from education about how FQHCs can provide mifepristone for abortion care while complying with federal funding restrictions. IMPLICATIONS: Learning collaboratives like ExPAND can prepare primary care clinics to provide mifepristone. Participants describe a clear benefit of mifepristone integration to their patients, and they report mifepristone integration aligns with clinic values.

Racial and ethnic disparities in short interval pregnancy following delivery in Catholic vs non-Catholic hospitals among California Medicaid enrollees.

OBJECTIVES: We examined the impact of Catholic hospital delivery on short interval pregnancy in the California 2010-2014 Medicaid population. STUDY DESIGN: We used Cox regression to estimate the association between hospital affiliation and short interval pregnancy, adjusting for patient factors. RESULTS: Catholic hospital delivery had increased the risk of pregnancy within 6 months for Black (hazard ratio [HR] 1.11, 95% CI 1.06, 1.17) and Hispanic (HR 1.07, 95% CI 1.05, 1.09) but not for White women (HR 1.02, 95% CI 0.98, 1.05). CONCLUSIONS: Among California women with Medicaid, Catholic hospital delivery was associated with short interval pregnancy only among women of color.

Pharmacists' experiences dispensing misoprostol and readiness to dispense mifepristone.

BACKGROUND: Mifepristone, followed by misoprostol, is commonly used for medication abortion and early miscarriage care. Since mifepristone's approval in 2000, the Food and Drug Administration (FDA) has placed restrictions on where and how it could be dispensed, including applying a Risk Evaluation and Mitigation Strategy in 2011. In December 2021, the FDA removed the in-person dispensing requirement and, in January 2023, began allowing certified pharmacies to dispense the drug directly to patients. OBJECTIVES: To explore pharmacist knowledge about misoprostol and mifepristone, experience dispensing misoprostol, as well as comfort and readiness to dispense mifepristone should federal regulations allow. METHODS: We conducted in-depth interviews with 21 U.S.-based pharmacists and pharmacy trainees between June and December of 2021, a time when few pharmacists were allowed to dispense mifepristone. RESULTS: Participants reported varied knowledge about medications for miscarriage and abortion but described themselves as generally knowledgeable about medications and reported strategies for learning about new medications. Most said they would feel ready to dispense mifepristone, and many described dispensing misoprostol without difficulty. Potential challenges specific to mifepristone dispensing included employer hesitation and colleague refusals. To assure successful dispensing, participants recommended basic training and fact sheets; relationships with prescribers for follow-up; and policies for prescription transfers in the event of refusal. CONCLUSIONS: We found that nearly all participants would feel ready to dispense mifepristone with some basic training. Pharmacists self-report having the skills and resources to learn about new medications quickly. Our findings support the FDA's rule change allowing pharmacist dispensing of mifepristone and suggest that most challenges would stem from individual or institutional refusals.

Reproductive care in community health centers: Multi-method evaluation of the Illinois Contraceptive Access Now (ICAN!) demonstration program.

OBJECTIVES: Nearly one-third of low-income women of reproductive age in the U.S. receive care in federally qualified community health centers, but comprehensive reproductive care is not consistently provided. Illinois Contraceptive Access Now (ICAN!) is an initiative addressing the access gap to high-quality contraceptive care with a focus on normalizing reproductive health screening for patients in federally qualified community health centers (FQHCs). STUDY DESIGN: This multi-method program evaluation used the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework, with retrospective and prospective data collection from three Illinois FQHCs who participated as Quality Hubs, and from a Community Advisory Board. We conducted descriptive analysis of patient surveys using the Person-Centered Contraceptive Counseling (PCCC) measure (n = 142); clinician and staff pre-and post-training surveys (n = 210); and Community Advisory Board surveys (n = 8) collecting quantitative and qualitative feedback. We ran logistic regression on claims data from 15- to 49-year-old patients identified as female at birth (n = 103,756). RESULTS: Reach assessment showed patients receiving contraceptive or preconception care increased from 1063 per month in 2020 to 1236 per month in 2021 (16% increase), while general volume increased 2%. Effectiveness showed most patients (78%) described the quality of contraceptive counseling as "excellent" on the PCCC. Adoption assessment showed knowledge increases after clinical training on Modern Contraception (85% pre-training, 95% post-training) and Reproductive Justice (RJ) (58% pre-training, 70% post-training). Implementation assessment found that most Community Advisory Board members felt ICAN! was responsive to community needs. CONCLUSIONS: The ICAN! demonstration year increased provider knowledge and volume of reproductive care at three Illinois FQHCs. IMPLICATIONS: Contraceptive access initiatives that operationalize same day access to birth control methods while training FQHC providers on RJ and modern contraception, show promise on several measures. Early evidence from ICAN! indicates increased reproductive health service provision, as well as increases in provider knowledge of RJ and modern contraceptive care.

Preconception care utilization: Self-report versus claims-based measures among women with Medicaid.

The objective of this study is to compare self-reported preconception care utilization (PCU) among Medicaid-covered births to Medicaid claims. We identified all Medicaid-covered births to women ages 15-45 in 26 states in the year 2012 among the Pregnancy Risk Assessment and Monitoring System (PRAMS) survey and Medicaid Analytic eXtract (MAX) claims data, and identified preconception services in the latter using diagnosis codes published by Health and Human Services' Office of Population Affairs. We fit mixed-effects logistic regression models for the probability of PCU on sociodemographic factors (age, race, and ethnicity) and clinical diagnoses (depression, diabetes, or hypertension), separately for each dataset. Among 652,929 women delivering in MAX, 28.1% received at least one claims-based preconception service while an estimated 23.6% (95% CI 22.1-25.3) of PRAMS respondents reported receiving preconception care. Adjusting for age, chronic diseases, and state, PCU rates in both MAX and PRAMS were higher for non-Hispanic Black versus non-Hispanic White women (OR 1.51, 95% CI 1.49-1.54 and OR 2.05, 95% CI 1.60-2.62, respectively). Adjusting for differences in age, race and ethnicity, and state, PCU rates were higher for patients with diabetes (OR 1.34, 95% CI 1.29-1.40 and OR 1.82, 95% CI 1.16-2.85) or hypertension (OR 1.22, 95% CI 1.18-1.27 and OR 1.85, 95% CI 1.41-2.44). While Hispanic and Asian women were also more likely to report PCU than their non-Hispanic White counterparts (OR 2.07, 95% CI 1.53-2.80 and OR 3.37, 95% CI 2.28-4.98), they were less likely to have received it (OR 0.74, 95% CI 0.73-0.75 and OR 0.65, 95% CI 0.63-0.67). In conclusion, comparing self-report to claims measures of PCU, we found similar trends in the differences between non-Hispanic Black and White women, and between those with vs. without diabetes and hypertension. However, the two data sources differed in trends in other racial/ethnic groups (differences between Hispanic vs. non-Hispanic White women, and between Asian vs. non-Hispanic White women), and in those with vs. without depression. This suggests that while Medicaid claims can be a useful tool for studying preconception care, they may miss certain types of care among some sub-groups of the population or be subject to reporting differences that are hard to surmise. Both data sets have potential benefits and drawbacks as research tools.

Preconception, Interconception, and reproductive health screening tools: A systematic review.

OBJECTIVE: To identify and describe the standardized interconception and preconception screening tools for reproductive health needs that are applicable in general outpatient clinical practice. DATA SOURCES AND STUDY SETTING: This systematic review identifies research on pregnancy intention screening and counseling tools, and standardized approaches to preconception and interconception care. We focus on tools designed for clinical settings, but also include research tools with potential for clinical implementation. These tools may include a component of contraceptive counseling, but those focusing solely on contraceptive counseling were excluded. Data were collected from studies done in the United States between January 2000 and March 2022. STUDY DESIGN: We performed a systematic literature search to generate a list of unique tools, assessed the quality of evidence supporting each tool, and described the peer-reviewed clinical applications of each. We used the Mixed Methods Appraisal Tool to appraise the quality of individual studies. DATA COLLECTION/EXTRACTION METHODS: We searched PubMed, Web of Science, and CINAHL databases for standardized preconception and interconception health screening tools published in English from January 2000 through March 2022. We used keywords "preconception care," "interconception care," "family planning," "contraception," "reproductive health services," and "counseling." Utilizing the Preferred Reporting Items for Systematic Reviews guidelines, we screened titles and abstracts to identify studies for full text review. PRINCIPAL FINDINGS: The search resulted in 15,399 studies. After removing 4172 duplicates, we screened 11,227 titles/abstracts and advanced 207 for full-text review. From these, we identified 53 eligible studies representing 22 tools/standardized approaches, of which 10 had evidence from randomized clinical trials. These ranged widely in design, setting, and population of study. CONCLUSIONS: Clinicians have a choice of tools when implementing standard reproductive screening services. A growing body of research can inform the selection of an appropriate tool, and more study is needed to establish effects on long-term patient outcomes.

Barriers to abortion provision in primary care in New England, 2019-2020: A qualitative study.

OBJECTIVE: To assess barriers to and facilitators of abortion provision among abortion-trained primary care providers. STUDY DESIGN: We conducted 21 qualitative in-depth interviews with 20 abortion-trained family physicians and one internal medicine physician in five New England states. We dual-coded interviews, using a consensus method to agree upon final coding schema. Through iterative dialogue, using an inductive content analysis approach, we synthesized the themes and identified patterns within each domain of inquiry. RESULTS: The most commonly reported barriers were a lack of organizational support, the Hyde Amendment, which prevents the use of federal funds for most abortion care, and the mifepristone Risk Evaluation and Mitigation Strategy, a federal regulation which prohibits routine mifepristone pharmacy dispensing. The logistical barriers created by these policies require cooperation from additional stakeholders, creating more opportunities for abortion stigma and moral opposition to arise. Other salient barriers included inter-specialty tension (particularly with obstetrician-gynecologists), perceived need for pre-abortion ultrasound, absence of a clinician support network, and lack of knowledge of existing resources for establishing abortion care in primary care. CONCLUSIONS: Increased abortion provision in primary care is one of many necessary responses to the human rights crisis produced by the Dobbs decision. Eliminating the Hyde Amendment and ending federal regulations restricting pharmacy dispensing of mifepristone are key interventions to address barriers to primary care abortion provision. Building interspecialty partnerships between family medicine and OB/GYN and spreading awareness of the evidence-based ultrasound-as-needed protocol and other educational resources are also likely to increase primary care abortion access. IMPLICATIONS: By exploring barriers to and facilitators of primary care abortion provision, this study outlines a targeted approach to support increased access to abortions. In states with legal abortion post-Roe, it is important that motivated and trained primary care providers can offer abortions, rather than referring patients to overburdened specialty clinics.

"This has definitely opened the doors": Provider perceptions of patient experiences with telemedicine for contraception in Illinois.

CONTEXT: The COVID-19 pandemic increased the provision of contraception through telemedicine. This qualitative study describes provider perceptions of how telemedicine provision of contraception has impacted patient care. METHODS: We interviewed 40 obstetrics-gynecology and family medicine physicians, midwives, nurse practitioners, and support staff providing contraception via telemedicine in practices across Illinois, including Planned Parenthood of Illinois (PPIL) health centers. We analyzed interview content to identify themes around the perceived impact of telemedicine implementation on contraception access, contraceptive counseling, patient privacy, and provision of long-acting reversible contraception (LARC). RESULTS: Participants perceived that telemedicine implementation improved care by increasing contraception access, increasing focus on counseling while reducing bias, and allowing easier method switching. Participants thought disparities in telemedicine usage and limitations to the technological interface presented barriers to patient care. Participants' perceptions of how telemedicine implementation impacts patient privacy and LARC provision were mixed. Some participants found telemedicine implementation enhanced privacy, while others felt unable to ensure privacy in a virtual space. Participants found telemedicine modalities useful for counseling patients considering methods of LARC, but they sometimes presented an unnecessary extra step for those sure about receiving one at a practice offering same day insertion. CONCLUSION: Providers felt telemedicine provision of contraception positively impacted patient care. Improvements to counseling and easier access to method switching suggest that telemedicine implementation may help reduce contraceptive coercion. Our findings highlight the need to integrate LARC care with telemedicine workflows, improve patient privacy protections, and promote equitable access to all telemedicine modalities.

Telehealth for contraceptive care: Lessons from staff and clinicians for improving implementation and sustainability in Illinois.

Objective: To solicit Illinois staff and clinician perspectives on rapid implementation of telehealth for contraceptive counseling and recommendations to improve and sustain it in the long term. Study design: Researchers recruited and interviewed clinicians (n = 20) in primary care and obstetrics/gynecology clinics across 13 health care systems in Illinois, as well as clinicians (n = 11), leadership (n = 6) and staff (n = 7) from Planned Parenthood of Illinois clinics. Guided by the Consolidated Framework for Implementation Research, we coded and analyzed interview transcripts in Dedoose with a focus on themes regarding steps to improve quality and sustainability of telehealth. Results: Participants expressed generally positive attitudes towards telehealth, noting that it increased access to care and time for patient education. Still, many highlighted areas of implementation that needed improvement. Clinic operations were complicated by gaps in telehealth training and the logistical needs of balancing telehealth and in-person appointments. Clinics had difficulty ensuring patient awareness of telehealth as an option for care, in addition to deficiencies with the telehealth technology itself. Finally, innovative resources for telehealth patients, while existent, have not been evenly offered across clinics. This includes the use of self-injection birth control, as well as providing medical equipment such as blood pressure cuffs in community settings. Some themes reflect issues specific to contraceptive counseling while others reflect issues with telehealth implementation in general, including confusion about reimbursement. Conclusion: Illinois contraceptive care providers and staff wish to sustain telehealth for the long term, while also recommending specific improvements to patient communications, clinic operations, and access to supportive resources. Implications: Our study highlights considerations for clinics to optimize implementation of telehealth services for contraceptive care. Providers described the value of clear workflows to balance in-person and telehealth visits, streamlined communications platforms, targeted patient outreach, training on providing virtual contraceptive care, and creative approaches to ensuring patient access to resources.

Beyond Hobby Lobby: Employer's responsibilities and opportunities to improve network access to reproductive healthcare for employees.

The majority of United States (US) women age 15-49 have employer-sponsored health insurance, but these insurance plans fall short if employees cannot find providers who meet reproductive health needs. Employers could and should do more to facilitate and advocate for their employees through the insurance plans they sponsor. We conducted interviews with 14 key informants to understand how large United States employers see their role in health insurance benefits, especially when it comes to reproductive health care access and restrictions in religious health systems. Our findings suggest that large employers wish to be responsive to their employees' health insurance priorities and have leverage to improve access to reproductive health services, but they do not take sufficient action toward this end. In particular, we argue that large employers could pressure insurance carriers to address network gaps in care resulting from religious restrictions and require insurers to treat out-of-network providers like in-network providers when reproductive care is restricted.

Facilitators of and Barriers to Successful Implementation of the One Key Question® Pregnancy Intention Screening Tool.

Background: One Key Question® (OKQ) is a tool that embeds a patient-centered screening into routine visits with the goal of making pregnancy intention screening universal, but widespread implementation has not yet been adopted. We aimed to explore the barriers and facilitators of OKQ implementation to better understand how to best implement the tool across different settings. Methods: We invited staff and clinicians from one obstetrics and gynecology clinic and one family medicine clinic, which previously implemented OKQ, to complete surveys and qualitative interviews about their experiences with the tool. The interview guide and thematic analysis of the interview transcripts were informed by the Consolidated Framework for Implementation Research (CFIR). Main Findings: Major facilitators of OKQ implementation are the simplicity of the tool, engagement of clinic leadership, and compatibility between the perceived goals of the tool and those of practice staff and clinicians. Although participants indicated that OKQ had a minimal impact on clinic workflow during its implementation, preimplementation time concerns were a major barrier to implementation in both clinics. Barriers seen in the family medicine practice included OKQ distracting from the visit agenda, and concerns about the OKQ gold standard protocol of screening each patient at every visit. Participants even suggested asking OKQ only during annual check-up appointments. Conclusions: The perceived alignment between the tool's goals and those of clinic stakeholders was an important facilitator of OKQ implementation success. However, characteristics of the clinic setting, such as competing medical priorities and time constraints, influenced initial attitudes toward the feasibility of the intervention. Clinical Trial Registration Number: NCT03947788.

Provider and community stakeholder perspectives of expanding Medicaid coverage of abortion in Illinois.

BACKGROUND: Many people seeking abortion encounter financial difficulties that delay or prevent them from accessing care. Although some patients qualify for Medicaid (a public program that can help cover health care costs), laws in some states restrict the use of Medicaid for abortion care. In 2017, Illinois passed House Bill 40 (HB-40), which allowed patients with Medicaid to receive coverage for their abortion. This study aimed to understand how HB-40 affected abortion affordability from the perspectives of individuals that work directly or indirectly with abortion patients or facilities providing abortion care. METHODS: We conducted interviews with clinicians and administrators from facilities that provided abortion services; staff from organizations that provided resources to abortion providers or patients; and individuals at organizations involved in the passage and/or implementation of HB-40. Interviews were audio-recorded and transcribed. We created codes based on the interview guides, coded each transcript using the web application Dedoose, and summarized findings by code. RESULTS: Interviews were conducted with 38 participants. Participants reflected that HB-40 seemed to remove a significant financial barrier for Medicaid recipients and improve the experience for patients seeking abortion care. Participants also described how the law led to a shift in resource allocation, allowing financial support to be directed towards uninsured patients. Some participants thought HB-40 might contribute to a reduction in abortion stigma. Despite the perceived positive impacts of the law, participants noted a lack of public knowledge about HB-40, as well as confusing or cumbersome insurance-related processes, could diminish the law's impact. Participants also highlighted persisting barriers to abortion utilization for minors, recent and undocumented immigrants, and people residing in rural areas, even after the passage of HB-40. CONCLUSIONS: HB-40 was perceived to improve the affordability of abortion. However, participants identified additional obstacles to abortion care in Illinois that weakened the impact of HB-40 for patients and required further action, Findings suggest that policymakers must also consider how insurance coverage can be disrupted by other legal barriers for historically excluded populations and ensure clear information on Medicaid enrollment and abortion coverage is widely disseminated.

Short-interval pregnancy in the Illinois Medicaid population following delivery in Catholic vs non-Catholic hospitals.

OBJECTIVE: Catholic hospitals restrict access to comprehensive reproductive health services that could impact patient outcomes. We sought to determine whether delivery at a Catholic hospital is associated with shorter pregnancy intervals among patients insured by Medicaid in Illinois. STUDY DESIGN: We used Illinois Medicaid data files to conduct a retrospective cohort study. We used billing codes to identify deliveries in 2010 and 2011 and classified each by a hospital of delivery, maternal age, race/ethnicity, and residential zip code. We calculated the interval from index birth to subsequent conception using an established method and used Cox proportional hazards regression to compare the rate of subsequent pregnancy between enrollees who delivered in Catholic vs non-Catholic hospitals, adjusting for individual characteristics. We also computed differences in the rates of conception within 6-, 12-, and 18-month intervals. RESULTS: We identified 96,293 index births and 18,627 subsequent conceptions. Twenty-eight percent (26,775) of index births occurred in a Catholic hospital. Women who delivered in a Catholic hospital had a 12% greater risk of conception in the following 18 months (HR 1.12, 95% CI 1.09-1.16) after adjusting for age, race/ethnicity, and rural residence. At 18 months, 23.9% of enrollees delivering in a Catholic hospital had become pregnant as compared to 21.2% for enrollees delivering in a non-Catholic hospital (difference of 2.6%, 95% CI 1.8-3.6). CONCLUSION: Illinois Medicaid enrollees who deliver at Catholic hospitals have an increased risk of short-interval pregnancy. As the market share of Catholic hospitals grows, providers must work with patients to acknowledge and address these potential impacts on reproductive health outcomes and policies must change to promote equitable access. IMPLICATIONS: Delivery at a Catholic hospital is associated with an increased risk of short-interval pregnancy. Further attention from providers, researchers, and policymakers alike, is necessary to identify the mechanisms through which these differences manifest such that effective interventions can be developed.

Faculty and Resident Contraceptive Opt Outs and Training Site Restrictions: A CERA Study.

BACKGROUND AND OBJECTIVES: Contraception is a core component of family medicine residency curriculum. Institutional environments can influence residents' access to contraceptive training and thus their ability to meet the reproductive health needs of their patients. METHODS: Contraceptive training questions were included in the 2020 Council of Academic Family Medicine Educational Research Alliance (CERA) survey of family medicine residency program directors. The survey asked how many faculty and residents opt out of providing contraceptive methods for moral or religious reasons, and whether training sites have institutional restrictions on contraception. We performed descriptive statistics and regression to identify program characteristics associated with having a resident or faculty opt out of providing contraceptive care. RESULTS: Of 626 program directors, 249 responded to the survey, and 237 answered the contraceptive questions. Percentages of program directors reporting any residents or faculty who opted out of contraceptive services are as follows: pill/patch/ring (residents 27%; faculty 17%), emergency contraception (residents 40%, faculty 33%), or intrauterine devices/implants (resident 29%; faculty 23%). Programs in the South (OR 2.78; 1.19-6.49) and those with Catholic affiliation (OR 2.35; 1.23-4.91) had higher adjusted odds of at least one opt-out faculty but were not associated with having opt-out residents. Eleven percent of programs had at least one training site with institutional restrictions on contraception. CONCLUSIONS: To ensure that residents have access to adequate contraceptive training, residencies should proactively seek faculty and training environments that meet residents' needs, and should make limitations on services clear to potential residents and patients.

Preconception care and severe maternal morbidity in the United States.

BACKGROUND: In the United States, approximately 52,000 women per year (accounting for 1.46% of births) experience severe maternal morbidity, which is defined as a complication that causes significant maternal harm or risk of death. It disproportionately affects women from racial or ethnic minorities, people with chronic diseases, and those with Medicaid or no insurance. Preconception care has been hailed as a strategy to improve pregnancy outcomes and reduce disparities, but its broad benefits for maternal outcomes have not been demonstrated. OBJECTIVE: Our objective was to measure the association between preconception care and the odds of severe maternal morbidity among women with Medicaid. STUDY DESIGN: This is a secondary analysis of Medicaid claims using the Medicaid Analytic Extract files (2010-2012). We used the International Classification of Diseases, Ninth Revision codes, published by the US Office of Population Affairs' Quality Family Planning program to define 7 domains of preconception care. The primary outcome was maternal death within 12 weeks of delivery or severe maternal morbidity during birth hospitalization, defined by the presence of any diagnosis or procedure on the severe maternal morbidity International Classification of Diseases, Ninth Revision code list from the Centers for Disease Control and Prevention. Because this list may overestimate severe maternal morbidity by counting any blood transfusion, our secondary outcome used the same code list but without transfusion. We reviewed care in the year before conception and used logistic regression to estimate the association between each domain and severe maternal morbidity for all births to women enrolled in Medicaid and aged 15 to 45 years with births during 2012. We performed a subgroup analysis for women with chronic disease (kidney disease, hypertension, or diabetes). RESULTS: Severe maternal morbidity or death occurred in 26,285 births (1.74%) when including blood transfusions and 9,481 births (0.63%) when excluding transfusions. Receiving contraceptive services in the year before conception was associated with decreased odds of severe maternal morbidity (adjusted odds ratio, 0.92; 95% confidence interval, 0.88-0.95) and pregnancy test services were associated with increased odds (adjusted odds ratio, 1.08; 95% confidence interval, 1.01-1.14). In the primary analysis, no significant associations were observed for other preconception care domains. Among those women with at least 1 chronic disease, contraceptive care (adjusted odds ratio, 0.84; 95% confidence interval, 0.75-0.95) and routine physical or gynecologic exams (adjusted odds ratio, 0.79; 95% confidence interval, 0.71-0.88) were associated with decreased odds of severe maternal morbidity. Similar associations were found for severe maternal morbidity when excluding blood transfusion. CONCLUSIONS: Contraceptive services in the year before conception and routine exams for women with chronic disease are associated with decreased odds of severe maternal morbidity or death for Medicaid enrollees.

What you don't know can hurt you: Patient and provider perspectives on postpartum contraceptive care in Illinois Catholic Hospitals.

OBJECTIVE: Catholic Religious and Ethical Directives restrict access to contraception; yet offering contraception during a delivery hospitalization facilitates birth spacing and is a convenient option for patients during the postpartum period. We assessed patient and provider experiences with hospital transparency around postpartum contraceptive care in Illinois Catholic Hospitals. STUDY DESIGN: We interviewed 44 participants with experience in Illinois Catholic Hospitals: 21 patients, and 23 providers, including clinicians, nurses, doulas, and postpartum program staff. We used an open-ended interview approach, with a semistructured guide focused on postpartum contraceptive care. We conducted interviews by phone between November 2019 and June 2020. We audio-recorded interviews, transcribed them verbatim, and coded transcripts in Dedoose. We developed narrative memos for each code, identifying themes and subthemes. We organized these in a matrix for analysis and present here themes regarding hospital transparency that emerged across interviews. RESULTS: Many patients knew they were delivering in a Catholic hospital; however, few were aware that Catholic policies limited their health care options. Patients expressed a desire for hospitals to be transparent, even "very vocal," about religious restrictions and described consequences of restrictions on patient care. Patients lacked information to make contraceptive decisions, experienced limits on or delays in care, and some lost continuity with trusted providers. Consequences for providers included moral distress in trying to provide care using workarounds such as documenting false medical diagnoses. CONCLUSIONS: Religious restrictions on postpartum contraception restrict access, cause unnecessary delays in care, and lead to misdiagnosis and marginalization of contraceptive care. Restrictions also cause moral distress to providers who balance career repercussions and professional integrity with patient needs. IMPLICATIONS: To protect patient autonomy, especially during the vulnerable postpartum period, Catholic hospitals should increase transparency regarding limitations on reproductive health care. Insurers and policy-makers should guarantee that patients have the option to receive care at hospitals without these limitations and facilitate public education about what to expect at Catholic facilities.