Over-the-Counter Oral Contraception as an Opportunity to Reduce Contraceptive Access Inequity.

This Viewpoint argues that making a progestin-only contraceptive pill available for sale as an over-the-counter product will help reduce logistic barriers to safe and effective birth control.

Enabling Factors Associated with Receipt of Interconception Health Care.

OBJECTIVES: Preventive health care between pregnancies may benefit future pregnancies and women's long-term health, yet such care is frequently incomplete. We used Andersen's Model of Health Services Use to identify factors associated with receipt of interconception care. METHODS: This secondary analysis uses data from a trial that recruited women from four health centers in the Baltimore metropolitan area. We used data on factors associated with Andersen's model reported up to 15 months postpartum. Factors included health history (diabetes, hypertension, prematurity), self-rated health, demographics (age, race/ethnicity, education, marital status, employment, income, parity), predisposing factors (depression, stress, social support), and enabling factors (usual place of care, personal doctor or nurse, insurance). Relative risk regression modeled the relationship between these factors and a dependent variable defined as completing both a postpartum visit and one subsequent health care visit. Models also accounted for time since birth, clustering by site, and trial arm. RESULTS: We included 376 women followed a mean of 272 days postpartum (SD 57), of whom 226 (60%) completed a postpartum and subsequent visit. Women were predominantly non-Hispanic Black (84%) and low income (50% household income < $20,000/year). In regression, two enabling factors were associated with increased receipt of care: having a personal doctor or nurse (RR 1.38, 95% CI 1.11-1.70) and non-Medicaid insurance (RR 1.64, 95% CI 1.09-2.56). CONCLUSIONS FOR PRACTICE: Enabling factors were associated with receipt of recommended care following birth. These factors may be modifiable components of efforts to improve care during this critical life course period.

Cluster Randomized Trial of a Pre/Interconception Health Intervention for Mothers in Pediatric Visits.

OBJECTIVE: Recognizing that pediatric primary care focuses on family health and is an important location of contact for women of childbearing age, this project assessed the effectiveness of a pre/interconception women's health intervention delivered during pediatric primary care using a cluster randomized trial. METHODS: Pediatric clinicians were randomized to a screening and brief educational intervention group or usual care comparison group. Intervention group clinicians received training on pre/interconception care, including recommended counseling and referral resources for needs identified. Women presenting to primary care with their child ≤12 months were enrolled and assigned to the group corresponding to the assignment of their child's clinician. Mothers seen by clinicians in the intervention group completed a pre/interconception health screening tool and discussed results with their child's clinician during the visit. These mothers were compared to mothers seen by comparison group clinicians who did not receive the screening tool or clinician discussion. All enrolled mothers (Intervention and Comparison) received written preconception health information and a 90-day supply of multivitamins. Primary outcomes at 6 and 12 months post enrollment included contraception use, pregnancy, and access to and use of preventive health care. Secondary outcomes included daily folic acid supplementation, smoking, and substance use. RESULTS: A total of 415 women were enrolled and those who had at least 1 follow-up assessment were included in the analysis (n = 383). There was no significant effect of the intervention on contraceptive use, pregnancy incidence, or use of preventive care. Assignment to the intervention increased the odds of daily folic acid use (odds ratio 1.82, 95% confidence interval 1.25, 2.63) during follow-up. Intervention mothers were less likely to smoke at 6, but not 12 months. CONCLUSIONS: Pediatric visits are an opportune location for addressing maternal health and this intervention demonstrated feasibility and improved outcomes for some but not all outcomes. Attention to maternal health needs in pediatric visits during infancy may be important for maintaining positive pre/interconception health behaviors.

Emergency Contraception.

Despite significant declines over the past 2 decades, the United States continues to experience birth rates among teenagers that are significantly higher than other high-income nations. Use of emergency contraception (EC) within 120 hours after unprotected or underprotected intercourse can reduce the risk of pregnancy. Emergency contraceptive methods include oral medications labeled and dedicated for use as EC by the US Food and Drug Administration (ulipristal and levonorgestrel), the "off-label" use of combined oral contraceptives, and insertion of a copper intrauterine device. Indications for the use of EC include intercourse without use of contraception; condom breakage or slippage; missed or late doses of contraceptives, including the oral contraceptive pill, contraceptive patch, contraceptive ring, and injectable contraception; vomiting after use of oral contraceptives; and sexual assault. Our aim in this updated policy statement is to (1) educate pediatricians and other physicians on available emergency contraceptive methods; (2) provide current data on the safety, efficacy, and use of EC in teenagers; and (3) encourage routine counseling and advance EC prescription as 1 public health strategy to reduce teenaged pregnancy.

Improving LARC Access for Urban Adolescents and Young Adults in the Pediatric Primary Care Setting.

The objective of this quality improvement study was to assess the feasibility, acceptability, and impact of integrating long-acting reversible contraceptive (LARC) delivery services into an academic pediatric primary care practice. Adolescent medicine providers in Baltimore, Maryland, were trained in LARC placement with gynecology providers integrated to offer onsite LARC placement and procedural support. Referrals, appointments, and contraceptive method choice/receipt were tabulated. Of 212 individuals referred for LARC consultations, 104 attended appointments. LARC placement at the initial referral increased from year 1 (N = 1) to year 2 (N = 42; P < .01). Adolescent medicine providers placed more LARCs in year 2 (N = 34) than year 1 (N = 0; P < .01). Patients aged 18 to 24 years were less likely to have a LARC placed than those aged 13 to 17 years (unadjusted odds ratio = 0.47 [0.26-0.86]). In conclusion, provider training and service integration of LARC services within a pediatric practice is feasible, acceptable, and increases LARC access and placement.

A System-Level Approach to Improve HIV Screening in an Urban Pediatric Primary Care Setting.

BACKGROUND AND OBJECTIVES: Less than 50% of youth living with HIV know their status. The Centers for Disease Control and Prevention and the United States Preventive Services Task Force recommend universal HIV screening in adolescence. Pediatric primary care settings are still lacking in testing youth who are at risk for HIV. Our objective was to determine whether implementing rapid HIV screening improved HIV screening rates and result receipt in 13- to 25-year-old pediatric primary patients. METHODS: From March 2014 to June 2015, a 4-cycle plan-do-study-act quality improvement model was used. A total of 4433 patients aged 13 to 25 years were eligible for HIV screening on the basis of Centers for Disease Control and Prevention criteria. Logistic regression with random effects was used to estimate the odds of HIV screening and screening with a rapid test compared with each previous cycle. Statistical process control charts using standard interpretation rules assessed the effect of patients receiving rapid HIV screening. RESULTS: Baseline HIV screening rate was 29.6%; it increased to 82.7% in cycle 4. The odds of HIV screening increased 31% between cycle 1 and baseline (odds ratio 1.31 [95% confidence interval: 1.01-1.69]) to a 1272% increase between cycle 4 and baseline (odds ratio 12.72 [95% confidence interval: 10.45-15.48]), with most (90.4%) via rapid screening. Rapid screening yielded higher same-day result receipt . Five patients were identified with HIV and immediately linked to on-site care. CONCLUSIONS: Rapid HIV screening and system-level modifications significantly increased screening rates and result receipt, revealing this to be an effective method to deliver HIV services to youth.

Integrating Pregnancy Prevention Into an HIV Counseling and Testing Program in Pediatric Primary Care.

PURPOSE: Certified health educator (CHE)-based HIV counseling and testing typically focus on HIV and sexually transmitted infection (STI) prevention only. A quality improvement initiative examined integrating assessment of reproductive life plans, counseling about pregnancy prevention, and contraception referral into a CHE-based HIV testing program. METHODS: Between February 2014 and January 2017, in one urban pediatric primary care clinic serving patients aged 0-25, CHEs assessed sexual history, HIV risk, short-term (i.e., the next 6-12 months) pregnancy desire, and current contraception method and satisfaction among patients aged 13-25 who had ever had vaginal sex, using a standardized questionnaire. Data were analyzed using a de-identified administrative dataset that also tracked referrals to initiate contraception and actual method initiation. RESULTS: Of 1,211 patients, most (96%) reported no short-term pregnancy or partner pregnancy desire. Use of less effective or no contraception, as well as method dissatisfaction, was common. A high proportion of female patients referred to new methods opted for more effective methods (62%) and initiated these methods (76%); a high proportion of male patients opted for receipt of condoms (67%). Patients reporting short-term pregnancy desire reported higher rates of previous pregnancy and STIs. CONCLUSIONS: Program findings highlight the potential benefit of integrating assessment for and counseling about pregnancy prevention in a CHE-based HIV testing program. This can more effectively address the needs of patients with concomitant risks of STI/HIV and unintended pregnancy, and link patients who do not desire pregnancy to more effective methods.

The Impact of Adolescent Dating Violence Training for Primary Care Providers.

OBJECTIVE: This study presents results from an educational training to increase adolescent dating violence (ADV) screening among primary care clinicians and provides adolescents' perceptions regarding discussing ADV with their clinicians. METHODS: A national dating violence advocacy group provided a training in ADV to 16 clinicians serving an urban health clinic. Knowledge, self-efficacy, and expectations were examined before training, after training, and at a 6-month follow-up. Forty-five adolescent patients of the clinicians were also surveyed. RESULTS: Analysis shows significant increases in clinician knowledge, self-efficacy, outcome expectancies, and outcome expectations after training and at the 6-month follow-up. About half of adolescents reported that they would disclose if they were in an abusive relationship and believed that their providers could help them. DISCUSSION: This training successfully improved clinician self-efficacy, outcome expectancies, knowledge, and behavioral capability regarding ADV. Additional research is needed to determine whether the training leads to improved ADV screening and intervention.

Effectiveness of a Pediatric Primary Care Intervention to Increase Maternal Folate Use: Results from a Cluster Randomized Controlled Trial.

OBJECTIVE: To assess the impact of provision of folate vitamins and a preconception health intervention on folate use among mothers bringing infants to pediatric primary care. STUDY DESIGN: We conducted a cluster randomized trial in mothers presenting with their infants (<12 months) at 4 urban pediatric practices in the Baltimore, Maryland, metropolitan area. There were 45 clinicians randomized into an intervention group (15-item preconception health screening and counseling and 90-day multivitamin supply) and control group (preconception health and community resource handouts and 90-day multivitamin supply). Participating mothers were enrolled in the study group assigned to their child's clinician. Baseline and 6-month follow-up interviews were performed. The outcome was daily use of folate, multivitamin, and a prenatal vitamin containing folate. Primary independent variables were time of assessment and mother's study group (intervention or control groups). Covariates investigated were mother's and child's age, race/ethnicity, education, marital status, income, insurance status, previous live births, and intention to have a pregnancy in the next 6 months. RESULTS: We enrolled 415 mothers at baseline who were majority African American and low income. Of the 415 enrolled participants, 352 (85%) completed follow-up interviews. Among all participants, daily vitamin intake increased from baseline to 6-month follow-up (33.8% vs 42.6%; P = .016). After adjustment for covariates and clustered design, there was an augmented effect in the intervention vs control group (aOR, 2.04; 95% CI, 1.04-3.98). CONCLUSIONS: Offering vitamins and recommending folate intake to mothers within pediatric practice can increase use. Pediatric practice is an important contact point and context for improving maternal folate use. TRIAL REGISTRATION: ClinicalTrials.govNCT02049554.

Why Didn't You Text Me? Poststudy Trends From the DepoText Trial.

OBJECTIVE: To evaluate the longitudinal impact of a 9-month text message intervention on participant adherence beyond the intervention to highly effective contraceptive methods among urban adolescent and young adult women enrolled in the DepoText randomized control trial (RCT). STUDY DESIGN: Retrospective longitudinal cohort study of long-term follow-up data from the DepoText RCT. Sixty-seven female participants (aged 13-21 years) using depot medroxyprogesterone acetate (DMPA) were recruited from an urban academic adolescent practice in Baltimore, Maryland. The principal outcome measured was a comparison of contraceptive method choice between the control and intervention groups during the 20 months postintervention. RESULTS: Intervention participants were 3.65 times more likely to continue using DMPA or a more efficacious method at the 20-month postintervention evaluation (odds ratio 3.65, 95% CI 1.26-10.08; P = .015). CONCLUSION: Participation in the DepoText trial was associated with continued use of DMPA or a more effective contraceptive method almost 20 months after the intervention exposure ended.

Right For Me: protocol for a cluster randomised trial of two interventions for facilitating shared decision-making about contraceptive methods.

INTRODUCTION: Despite the observed and theoretical advantages of shared decision-making in a range of clinical contexts, including contraceptive care, there remains a paucity of evidence on how to facilitate its adoption. This paper describes the protocol for a study to assess the comparative effectiveness of patient-targeted and provider-targeted interventions for facilitating shared decision-making about contraceptive methods. METHODS AND ANALYSIS: We will conduct a 2×2 factorial cluster randomised controlled trial with four arms: (1) video+prompt card, (2) decision aids+training, (3) video+prompt card and decision aids+training and (4) usual care. The clusters will be clinics in USA that deliver contraceptive care. The participants will be people who have completed a healthcare visit at a participating clinic, were assigned female sex at birth, are aged 15-49 years, are able to read and write English or Spanish and have not previously participated in the study. The primary outcome will be shared decision-making about contraceptive methods. Secondary outcomes will be the occurrence of a conversation about contraception in the healthcare visit, satisfaction with the conversation about contraception, intended contraceptive method(s), intention to use a highly effective method, values concordance of the intended method(s), decision regret, contraceptive method(s) used, use of a highly effective method, use of the intended method(s), adherence, satisfaction with the method(s) used, unintended pregnancy and unwelcome pregnancy. We will collect study data via longitudinal patient surveys administered immediately after the healthcare visit, four weeks later and six months later. ETHICS AND DISSEMINATION: We will disseminate results via presentations at scientific and professional conferences, papers published in peer-reviewed, open-access journals and scientific and lay reports. We will also make an anonymised copy of the final participant-level dataset available to others for research purposes. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov Identifier: NCT02759939.

Over-the-Counter Access to Oral Contraceptives for Adolescents.

Oral contraceptives (OCs) are used by millions of women in the U.S. The requirement to obtain OCs by prescription from a clinician may serve as a barrier to contraceptive initiation and continuation for women, in particular adolescents. Over-the-counter (OTC) availability would reduce this barrier and could further reduce unintended pregnancy rates. This review explores the scientific issues and regulatory processes involved in switching OCs to OTC status for minor adolescents. We review: (1) the regulatory criteria for switching a drug to OTC status; (2) risk of pregnancy and safety during use of OCs including combined oral contraceptives and progestin-only pills for adolescents; (3) the ability of adolescents to use OCs consistently and correctly; (4) OTC access to OCs and potential effect on sexual risk behaviors; and (5) the potential for reduced opportunities for clinicians to counsel and provide recommended reproductive health care to adolescents. We find strong scientific rationale for including adolescents in any regulatory change to switch OCs to OTC status. OCs are safe and highly effective among adolescents; contraindications are rarer among adolescents compared to adult women. Ready access to OCs, condoms, and emergency contraception increases their use without increasing sexual risk behaviors.

Optimizing Preconception Health among Young Women: What Are We Missing?

STUDY OBJECTIVE: To evaluate whether receipt of specific preconception counseling topics differs between teen, young adult, and older mothers. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: A survey of 291 primarily low-income, minority mothers with young children at pediatric practices in Baltimore, Maryland was conducted. Multivariable logistic regression models generated relative odds of preconception counseling receipt comparing teens (ages 14-19 years) and young adults (ages 20-24 years) to adult women (age ≥25 years) controlling for demographic characteristics, parity, and pregnancy intention. RESULTS: Teen mothers were less than half as likely to be counseled about taking folic acid, 4 times more likely to be counseled about vaccines, and twice as likely to be counseled about mental health before pregnancy compared with adult mothers. CONCLUSION: Adolescent preventive care might promote some aspects of preconception health, but topics related specifically to pregnancy outcomes might be missed. Because of the high rate of unplanned teen pregnancy in the United States, additional strategies to promote preconception health in this population are warranted.

The status of adolescent medicine: building a global adolescent workforce.

Remarkable public health achievements to reduce infant and child mortality as well as improve the health and well-being of children worldwide have successfully resulted in increased survival and a growing population of young people aged 10-24 years. Population trends indicate that the current generation of 1.8 billion young people is the largest in history. However, there is a scarcity of dedicated resources available to effectively meet the health needs of adolescents and young adults worldwide. Growing recognition of the pivotal roles young people play in the cultures, societies, and countries in which they live has spurred an expanding global movement to address the needs of this special population. Building an effective global workforce of highly-skilled adolescent health professionals who understand the unique biological, psychological, behavioral, social, and environmental factors that affect the health of adolescents is a critical step in addressing the health needs of the growing cohort of young people. In this review, we aim to: 1) define a global assessment of the health needs for adolescents around the world; 2) describe examples of current training programs and requirements in adolescent medicine; 3) identify existing gaps and barriers to develop an effective adolescent health workforce; and 4) develop a call for targeted actions to build capacity of the adolescent health workforce, broaden culturally relevant research and evidence-based intervention strategies, and reinforce existing interdisciplinary global networks of youth advocates and adolescent health professionals to maximize the opportunities for training, research, and care delivery.

The Association between Insurance Status and Acceptance of Chlamydia Screening By Teenagers Who Present for Preventive Care Visits.

STUDY OBJECTIVE: The purpose of this study was to evaluate whether providers offer chlamydia screening to teenagers and/or whether screening is accepted at different rates depending on insurance type. DESIGN: Retrospective chart review. SETTING: Academic center serving urban and suburban patients between April 2009 and October 2011. PARTICIPANTS: Nine hundred eighty-three health maintenance visits for asymptomatic, insured female adolescents aged 15-19 years. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Dichotomous dependent variables of interest indicated whether chlamydia screening was: (1) offered; and (2) accepted. The key independent variable insurance type was coded as 'public' if Medicaid or Medicaid Managed Care and 'private' if a commercial plan. χ(2) and logistic regression analyses were used to assess the significance of differences in screening rates according to insurance type. RESULTS: Of asymptomatic health-maintenance visits 933 (95%) had a documented sexual history and 339 (34%) had a documented history of sexual activity. After excluding those who had a documented chlamydia screen in the 12 months before the visit (n = 79; 23%), 260 visits met eligibility for chlamydia screening. Only 169 (65%) of eligible visits had chlamydia screening offered and there was no difference in offer of screening according to insurance type. Significantly more visits covered by public insurance had chlamydia screening accepted (98%) than those covered by private insurance (82%). Controlling for demographic factors, the odds of accepted chlamydia screening was 8 times higher in visits covered by public insurance than those with private insurance. CONCLUSION: Although publically and privately insured teens were equally likely to be offered chlamydia screening, publically insured teens were significantly more likely to accept screening. Future research should investigate reasons for this difference in screening acceptance. These findings have implications for interventions to improve chlamydia screening because more adolescents are covered by parental insurance under the Affordable Care Act.

Contraceptive service needs of women with young children presenting for pediatric care.

OBJECTIVES: The primary objective of this study is to characterize the need for contraceptive services and contraceptive method use among women with young children presenting to child health clinics. A secondary objective is to characterize the factors, including access to care and health needs, that exist in this population and to evaluate their association with contraceptive method use. STUDY DESIGN: This is a cross-sectional study of women with children under age 36 months presenting to four child health practices in the Baltimore, Maryland, area. Participating women completed a survey to assess desire for pregnancy, contraceptive method use and related characteristics. RESULTS: A total of 238 participants (82%) were in need of contraceptive services (fertile and not desiring pregnancy). Overall, 59 (25%) of women in need were not using a contraceptive method (unmet need) and 79 (33%) were using a highly effective method (implant or intrauterine device). Factors associated with lower odds of unmet need for contraceptive services included attendance at a routine postpartum visit and visiting a healthcare provider to discuss contraception after pregnancy. Approximately half of index pregnancies were unintended and this was the only health factor associated with greater odds of using of a highly effective contraceptive method. CONCLUSIONS: Most women presenting with young children for pediatric care indicated that they were not currently trying to become pregnant and reported current methods of pregnancy prevention that ranged from none to highly effective. Women who had not sought postpregnancy contraceptive care were more likely to have unmet need for contraceptive services. IMPLICATIONS: Child health clinics may be a novel site for providing contraceptive care to women with children as part of a strategy to reduce unplanned pregnancies.

Social disadvantage as a risk for first pregnancy among adolescent females in the United States.

PURPOSE: Differences in underlying determinants of pregnancy at different stages of adolescent development have implications for prevention strategies. We sought to determine whether social disparities in rates of adolescent pregnancy vary between early, middle, and late adolescence. We hypothesized that as age increases, racial and socioeconomic disparities in rates of teen conception decrease. METHODS: Data were obtained from the National Survey of Family Growth cycle 6. Outcome variables indicated whether respondents had a first pregnancy at ages <15 years, 15-17 years, or 18-19 years. Independent variables were race and maternal education level. Logistic regression was used to calculate the relative odds of first conception in a given age range by race and maternal education level. RESULTS: The disparity in odds of pregnancy between black and white teens is maximal in early adolescence (odds ratios <15 years: 3.9) and decreased by nearly 50% in late adolescence (odds ratios 18-19 years: 2.0, p < .01). After stratifying by maternal education level, the same trends are seen. CONCLUSIONS: In accordance with our hypothesis, we found that social disparities in pregnancy rates decrease between early and late adolescence. Although pregnancy prevention efforts often target those at social risk including poor minority youth, fewer acknowledge and target the risks associated with development of sexuality in all teens. Efforts to better define the nature of healthy adolescent sexual development may lead to pregnancy prevention interventions focused on developmental risk that can apply to a wider set of adolescents.

Impact of individual values on adherence to emergency contraception practice guidelines among pediatric residents: implications for training.

OBJECTIVE: To evaluate the impact of individual, system, and interpersonal factors on emergency contraception practices. We hypothesized that abortion attitudes and attitudes toward teen sex would be significant individual factors influencing emergency contraception practices. DESIGN: This was a cross-sectional, anonymous Internet survey. SETTING: Four pediatric residency programs in the Baltimore, Maryland-Washington, DC, metropolitan area during April to June 2007. PARTICIPANTS: One hundred forty-one pediatric residents completed the survey. MAIN EXPOSURE: Abortion attitudes were assessed by participants' level of agreement with abortion in 7 scenarios. Attitudes toward teen sex were assessed by participants' level of agreement with 5 statements about the acceptability of teens having sex. MAIN OUTCOME MEASURES: Emergency contraceptive counseling behavior was assessed by reported frequency of including emergency contraception in routine contraceptive counseling. Intention to prescribe emergency contraception was assessed by reported likelihood of prescribing in 5 scenarios. RESULTS: When controlling for demographics and other predictors, residents with less favorable abortion attitudes were more likely to have the lowest intention to prescribe emergency contraception. Residents with more positive attitudes toward teen sex and who had a preceptor encourage emergency contraception prescription were more likely to include emergency contraception in routine contraceptive counseling most/all the time and to have the highest intention to prescribe. CONCLUSION: Efforts to challenge and affect attitudes toward teen sex and to prompt residents to prescribe emergency contraception in clinical settings may be needed to encourage more proactive emergency contraceptive practice in accordance with national practice guidelines.