Contraceptive use following gestational trophoblastic disease: A systematic review.

OBJECTIVE: To systematically review the effect of contraceptive methods following gestational trophoblastic disease (GTD) on timing of beta-human chorionic gonadotropin (hCG) remission, risk of post-molar gestational trophoblastic neoplasia (GTN), risk of unintended incident pregnancy, and interactions between contraceptive methods and disease treatment. STUDY DESIGN: We conducted a search of primary literature with search terms related to GTD and contraception through April 2023 in PubMed and extrapolated our search to other platforms. Randomized controlled trials, observational studies and case reports were eligible for inclusion if they reported on patients with known GTD who received a contraceptive method for pregnancy prevention. Data was abstracted on our main outcomes of interest: timing of beta-hCG remission, risk of post-molar GTN, risk of unintended incident pregnancy, and interactions between contraceptive methods and cancer-directed systemic disease treatment (e.g., chemotherapy). At least two authors reviewed manuscripts at each screening stage with consensus reached before data extraction. Quality assessment checklists were used to assess risk of bias for the different study types. RESULTS: Five thousand one hundred and five studies were identified in the database search, of which 42 were included for analysis. Eight thousand two hundred and ninety four participants were evaluated. Over half of the studies were case reports and only two were randomized controlled trials. While there was sparse data on all outcomes, no differences were noted in beta-hCG monitoring, risk of post-molar GTN or incident pregnancies between different contraceptive types. Interactions between contraceptive methods and cancer-directed systemic disease treatment (e.g., chemotherapy) or specific adverse events of contraceptive methods were not identified. CONCLUSIONS: Data on contraceptive use following GTD is limited, but use of both hormonal and non-hormonal modern contraceptive methods appears safe. Counseling patients on the full range of contraceptive methods is important to help patients achieve their reproductive health goals and minimize the risk of disease progression through incomplete beta-hCG monitoring prior to future pregnancy. IMPLICATIONS: Hormonal and non-hormonal contraceptive options may be used by patients following gestational trophoblastic disease without apparent changes in beta-hCG regression or risk of post-molar gestational trophoblastic neoplasia.

Potential demand for and access to medication abortion among North Carolina college students.

OBJECTIVE: To estimate demand for medication abortion (MAB) among North Carolina (NC) college students and describe access to nearest clinics offering MAB to each campus. METHODS: We calculated demand using 2019-2020 campus demographics and NC abortion statistics. We used a mystery client technique to gather MAB cost and appointment wait times at the closest clinics and calculated travel distances and times. RESULTS: We estimated that 2,517 NC students seek MAB annually. Twenty-one clinics were closest to NC's 111 colleges and universities, including five in neighboring states. Mean cost was $450, with an average wait time of six days to appointment. The average round-trip travel distance was 58 miles and time to the nearest clinic was 84 min by car. CONCLUSIONS: Many NC college students likely obtain MAB every year and face high costs, long wait times and distances to care, which has likely worsened after the overturning of Roe v. Wade.

Contraceptive use and counseling in patients with systemic lupus erythematosus.

OBJECTIVES: (1) Describe contraception use in women with systemic lupus erythematosus (SLE); (2) characterize the types of contraception used by this population; (3) determine factors affecting the documentation of contraception use; (4) identify if contraception counseling was received in this population at risk for adverse pregnancy outcomes. STUDY DESIGN: This cross-sectional study analyzed data from clinic visits from 2016 - 2018 among 453 women of reproductive age who have SLE. Documentation of contraception use, contraception method, contraception counseling, and other medication use were abstracted from the medical record and analyzed with percentage based statistics, chi-squared test, t-test, and logistic regression. RESULTS: Of the 453 women included in the analysis, 71% had a method of contraception documented within 2 years of the study period. Only 37% were using highly effective contraception. 78% had documentation of contraception counseling. Half (50%) were using teratogenic medications; patients on teratogenic medications had higher odds of having a contraceptive method documented (OR 1.56, 95% CI 1.04 - 2.36) however 24% did not have any contraception documented. 28% of patients were using contraception for which they had a possible or absolute contraindication. CONCLUSIONS: Given a substantial proportion of women with SLE did not have any contraception or contraceptive counseling documented, these findings suggest the need to improve universal reproductive health counseling in patients with SLE. IMPLICATIONS: There is room to improve reproductive health care in patients with SLE through provider training to help optimize pregnancy outcomes in this high-risk population.

Comparing Website Identification for Crisis Pregnancy Centers and Abortion Clinics.

BACKGROUND: Crisis pregnancy centers (CPCs) seeking to dissuade women from abortion often appear in Internet searches for abortion clinics. We aimed to assess whether women can use screenshots from real websites to differentiate between CPCs and abortion clinics. METHODS: We conducted a cross-sectional, nationally representative online study of English- and Spanish-speaking women aged 18-49 years in the United States. We presented participants with screenshots from five CPCs and five abortion clinic websites and asked if they thought an abortion could be obtained at that center. We scored correct answers based on clinic type. Outcomes included ability to correctly identify CPCs and abortion clinics as well as risk factors for misidentification. The survey also included five questions about common abortion myths and a validated health literacy assessment. RESULTS: We contacted 2,223 women, of whom 1,057 (48%) completed the survey and 1,044 (47%) were included in the analysis. The median score for correctly identifying CPCs as facilities not performing abortion was 2 out of 5 (Q1: 0, Q3: 4). The median score for correctly identifying abortion clinics as facilities performing abortion was 5 out of 5 (Q1: 3, Q3: 5). Those less likely to endorse abortion myths had higher odds of correctly identifying CPCs (adjusted odds ratio, 2.43; 95% confidence interval, 1.78-3.32). A low health literacy score was associated with decreased odds of correct identification of CPCs (adjusted odds ratio, 0.39; 95% confidence interval, 0.25-0.59). CONCLUSIONS: Websites of CPCs were more difficult for women to correctly identify than those of abortion clinics. Women with limited knowledge about abortion and low health literacy may be particularly susceptible to misidentification of CPC websites.

Women's knowledge of their state's abortion regulations. A national survey.

OBJECTIVES: States vary significantly in their regulation of abortion. Misinformation about abortion is pervasive and propagated by state-mandated scripts that contain abortion myths. We sought to investigate women's knowledge of abortion laws in their state. Our secondary objective was to describe women's ability to discern myths about abortion from facts about abortion. STUDY DESIGN: This was a cross-sectional study of English- and Spanish-speaking women aged 18-49 in the United States. We enrolled members of the GfK KnowledgePanel, a probability-based, nationally-representative online sample. Our primary outcome was the proportion of correct answers to 12 questions about laws regulating abortion in a respondent's state. We asked five questions about common abortion myths. We used descriptive statistics to characterize performance on these measures and bivariate and multivariate modeling to identify risk factors for poor knowledge of state abortion laws. RESULTS: Of 2223 women contacted, 1057 (48%) completed the survey. The mean proportion of correct answers to 12 law questions was 18% (95% CI 17-20%). For three of five assessed myths, women endorsed myths about abortion over facts. Those who believe abortion should be illegal (aOR 2.18, CI 1.40-3.37), and those living in states with neutral or hostile state policies toward abortion (neutral aOR 1.99, CI 1.34-2.97; hostile aOR 1.6, CI 1.07-2.36) were at increased odds of poor law knowledge. CONCLUSIONS: Women had low levels of knowledge about state abortion laws and commonly endorse abortion myths. Women's knowledge of their state's abortion laws was associated with personal views about abortion and their state policy environment. IMPLICATIONS: Supporters of reproductive rights can use these results to show policy makers that their constituents are unlikely to know about laws being passed that may profoundly affect them. These findings underscore the potential benefit in correcting widely-held, medically-inaccurate beliefs about abortion so opinions about laws can be based on fact.

Stage-based implementation of immediate postpartum long-acting reversible contraception using a reproductive justice framework.

The immediate postpartum period is a favorable, safe, and effective time to provide long-acting reversible contraceptives, yet it is not available widely. We describe an innovative hospital-based approach to immediate postpartum long-acting reversible contraceptives that includes (1) an emphasis on multidisciplinary teambuilding and identification of champions, (2) a focus on the use of implementation science at every stage of the process to develop a systematic and replicable strategy, and (3) an imperative to apply a reproductive justice framework to immediate postpartum long-acting reversible contraceptive implementation. Our model was developed with the use of implementation science best practices. Implementation teams comprised of diverse stakeholders were formed and included champions to promote progress. Our team assessed the implementation context for immediate postpartum long-acting reversible contraceptives and used the findings to develop a readiness assessment for hospitals. A stage-based implementation checklist was then developed to outline necessary infrastructure to support an immediate postpartum long-acting reversible contraceptive initiative. A reproductive justice lens guided planning and implementation. The 3 innovative aspects of our implementation process resulted in a systematic, multidisciplinary, and culturally appropriate model for immediate postpartum long-acting reversible contraceptives that can be replicated across hospitals. Implementation teams and champions moved the work forward at each hospital, and 3 of the 5 participating hospitals moved beyond the exploration stage of implementation during the engagement. Patient education materials and provider training incorporated person-centered and reproductive justice frameworks. Our hope is to continue to partner with stakeholders to better understand how our efforts to support hospital provision of immediate postpartum long-acting reversible contraceptives can increase reproductive health equity rather than perpetuate disparity.

Prenatal Contraceptive Counseling by Video.

OBJECTIVE: Effective postpartum contraception can improve interpregnancy intervals. Opportunities exist for counseling and education during prenatal care. Few studies have assessed the use of multimedia as a tool to improve long-acting reversible contraception (LARC) use postpartum. The objective of this study was to evaluate whether LARC-focused video counseling during prenatal care increases uptake of postpartum LARC and overall contraception use. METHODS: In this randomized controlled trial, women receiving their prenatal care at a university-based resident clinic were randomized to receive LARC FIRST video contraceptive counseling along with routine prenatal care or routine prenatal care alone. All of the participants received information regarding access to free LARC methods in the postpartum period. The primary outcome was LARC uptake by 12 weeks postpartum. Secondary outcomes included overall contraception use at 12 weeks postpartum, postpartum visit attendance, and acceptability of video counseling. RESULTS: LARC use at 12 weeks postpartum rose from an estimated 6% preintervention to 39.4% (13/33) in the video group compared with 29.4% (10/34) of the control group. The difference between groups was not statistically significant. Although overall contraceptive use (72.7% vs 54.8%) and postpartum visit attendance (91% vs. 76.5%) were higher in the video group relative to the control group, these differences were not statistically significant. Participants overwhelmingly liked the video (95.2%, 41/42) and believed viewing it was a good use of their appointment time (92%, 38/42). CONCLUSIONS: LARC use increased 32% across the entire study cohort; however, video-based contraceptive counseling did not increase LARC uptake at 12 weeks postpartum compared with routine prenatal care alone. Patients viewing the video reported high levels of acceptability and improved contraceptive knowledge. Video counseling may be a useful adjunct in many clinical settings.

Evidence-based pregnancy testing in clinical trials: Recommendations from a multi-stakeholder development process.

Most clinical trials exclude pregnant women in order to avoid the possibility of adverse embryonic and/or fetal effects. Currently, there are no evidence-based guidelines regarding appropriate methods for identifying early pregnancy among research subjects. This lack of guidance results in wide variation in pregnancy testing plans, leading to the potential for inadequate protection against embryonic or fetal exposure in some cases and unnecessary burdens on research participants in others, as well as inefficiencies caused by disagreements among sponsors, investigators, and regulators. To address this issue, the Clinical Trials Transformation Initiative convened content experts and stakeholders to develop recommendations for pregnancy testing in clinical research based on currently available evidence. Recommendations included: 1) the study protocol should clearly state the rationale for pregnancy testing and the plan for handling positive and indeterminate tests; 2) protocols should include an assessment of the pregnancy testing plan advantages (reduced risk of embryo/fetal exposure) versus the burdens (participant burden, study team workload, costs); 3) protocols should assess the participant burdens regarding the likelihood of false negative and false positive results; 4) participant administered home pregnancy testing should be avoided in clinical trials; and 5) the consent process should describe the extent of knowledge about the study intervention's potential risk to the embryo/fetus and the limitations and consequences of pregnancy testing. CTTI has also developed an online tool to help implement these recommendations.

The Impact of a 72-hour Waiting Period on Women's Access to Abortion Care at a Hospital-Based Clinic in North Carolina.

BACKGROUND In 2015, North Carolina became the 5th state to pass legislation requiring women to undergo state-mandated counseling 72 hours prior to abortion. Whether this legislation has changed the timing of abortion decision-making or receipt of care is not known.METHODS This is a cross-sectional study using anonymous survey data from women presenting for abortion at a hospital-based abortion clinic in North Carolina. Data were collected for 8 weeks immediately before and after implementation of the new waiting period.RESULTS 26/48 (54%) of eligible patients participated. More than half (56%) of women made their abortion decision relatively quickly (less than or equal to 3 days), but had a median time-to-care of almost a week.LIMITATIONS This small study is the 1st recent evaluation of abortion decision-making and receipt of care immediately before and after implementation of a 72-hour waiting period in a Southern state. Only women presenting for care at a single hospital-based clinic were surveyed. Data were self-reported.CONCLUSION In our clinical setting, most women decided to have an abortion quickly but still waited 10-15 days before receiving care. Extended waiting periods provide no medical benefits and the potential for harm and delay of care remains.

Reproductive Life Planning: Raising the Questions.

Introduction Unintended pregnancy has been a concerning public health problem for decades. As we begin to understand the complexities of pregnancy intention and how women experience these pregnancies, reproductive life planning offers a paradigm shift. Methods Reproductive life planning is a patient-centered approach that places a patient's reproductive preferences-whether concrete or ambivalent-at the forefront of her clinical care. Results This process grants women and men the opportunity to consider how reproduction fits within the context of their broader lives. Within a clinical encounter, reproductive life planning allows counseling and care to be tailored to patient preferences. Discussion Although there is great potential for positive public health impacts in unintended pregnancy, contraceptive use and improved preconception health, the true benefit lies within reinforcing reproductive empowerment. Despite recommendations for universal adoption, many questions remain regarding implementation, equity and outcomes.

North Carolina Medical Student Views on Abortion.

BACKGROUND Abortion is a controversial yet common procedure within the United States and North Carolina. Although much effort has been directed at understanding the views of physicians and the general public, the views of medical students on abortion are understudied. This study examines the views of medical students at different stages in training on abortion at a public institution, the University of North Carolina at Chapel Hill School of Medicine.METHODS We surveyed incoming, second year, fourth year, and leave-of-absence medical students at the University of North Carolina at Chapel Hill about their views on abortion. We utilized an IRB-approved, anonymous online Qualtrics-based, cross-sectional survey during the spring of 2014.RESULTS We received 315 responses (58% response rate) from 98 incoming (54.5%), 126 second year (70.0%), and 91 fourth year and leave-of-absence (49.2%) students. The majority of students, regardless of stage of training, felt abortion was morally acceptable (incoming 64.3%, second year 74.0%, and fourth year and leave-of-absence 70.0%). Of the students who found abortion to be acceptable, second year (80.9%) and fourth year and leave-of-absence (85.5%) students found second-trimester abortion more acceptable than incoming students (57.15%, P = .002); second year students (42.2%) had greater acceptability of third-trimester abortions compared to incoming (26.2%) and fourth year and leave-of-absence students (22.2%; P = .03). Religiosity and Republican political affiliation were associated with more conservative views on abortion (P = .002); however, gender or intention to enter into an obstetrics/gynecology residency were not.LIMITATIONS Our study reflects views from a single institution, the University of North Carolina at Chapel Hill School of Medicine. This limits the generalizability of our findings to the greater population of medical students across the country.CONCLUSION Despite the controversy surrounding abortion, our work suggests that medical students at the University of North Carolina at Chapel Hill School of Medicine have accepting views of abortion.

Contraception Insurance Coverage and Receipt of Long-Acting Reversible Contraception or Depot Medroxyprogesterone Acetate on the Day of Abortion.

OBJECTIVE: To evaluate whether contraceptive insurance coverage for women who present for an abortion is associated with obtaining long-acting reversible contraception or depot medroxyprogesterone acetate (DMPA) on the day the abortion is completed. METHODS: We conducted a prospective cohort study of women presenting for medical or surgical abortion at a single health center in North Carolina. Eligible women were 18 years or older and fluent in English or Spanish. Data were from participant questionnaires, medical charts, and financial records. Our main exposure was whether the woman had insurance coverage for contraception at clinic intake. Our primary outcome was receiving DMPA, an intrauterine device, or a contraceptive subdermal implant on the same day of their surgical abortion or at the visit that determined their medication abortion was complete. We used univariable, bivariable, and multivariable analysis to report our findings. RESULTS: Five hundred seventy-five women enrolled in our cohort between September 2015 and April 2016. One hundred twenty-eight (22%) had insurance coverage and 447 (78%) did not. In the group with insurance coverage for contraception, 38% (49/128) received a long-acting reversible contraception method or DMPA compared with 7% (33/447) in the group without insurance coverage for contraception. After adjusting for confounding, women with contraceptive coverage were more than five times as likely to receive immediate postabortion contraception with one of these methods compared with women without coverage (relative risk 5.6, 95% confidence interval 3.8-8.3). CONCLUSION: Women with contraceptive insurance coverage on the day of their abortion were more likely to leave the abortion clinic with an intrauterine device or implant in place or receive DMPA injection compared with women without coverage.

Reassessing Unintended Pregnancy: Toward a Patient-centered Approach to Family Planning.

Underserved women, especially those with low incomes and from racial and ethnic minorities, experience a disproportionate share of unintended pregnancies in the United States. Although unintended pregnancy rates are general markers of women's health and status, they may not accurately capture women's experiences of these pregnancies or their social circumstances. A patient-centered approach to family planning optimizes women's reproductive preferences, is cognizant of historical harms and current disparities, and may more comprehensively address the issue of unintended pregnancy. Clinicians, researchers, and policy makers can all adopt a patient-centered approach to help underserved women regain their reproductive autonomy.

Abnormally elevated serum hCG in a patient with end-stage renal disease seeking abortion: to be expected or a cause for concern? A case report.

A patient with end-stage renal disease on hemodialysis was referred to our abortion clinic with a concern for molar pregnancy. By 12 weeks, her human chorionic gonadotropin (hCG) level was over 500,000. A review of the literature demonstrates that elevated hCG should be expected in this population and should not alter care.

Opportunities and barriers in global women's health training during obstetrics and gynecology residencies in the USA.

OBJECTIVE: To systematically measure the scope and breadth of global women's health (GWH) training opportunities during obstetrics and gynecology residencies in the USA, as described by program directors (PDs). METHODS: In a questionnaire-based study, PDs were asked to complete a web-based survey between January 1 and March 15, 2013. Information about the residency program and GWH opportunities was obtained. RESULTS: Among 236 PDs contacted, 105 (44.5%) responded. Overall, 82 (78.1%) reported that at least one resident had participated in a GWH rotation during the past 5 years, 36 (34.3%) offered formal didactics, and 29 (27.6%) offered a formal rotation in GWH. Among all respondents, 43 (42.2%) reported having at least one faculty member for whom GWH is a dedicated part of their practice. Programs with dedicated GWH faculty were more likely to offer formal GWH didactics (relative risk [RR] 1.84; 95% confidence interval [CI] 1.07-3.14; P=0.03), but were not significantly more likely to offer a formal GWH rotation (RR 1.91; 95% CI 0.97-3.70; P=0.06). CONCLUSION: Many residency programs provide opportunities for GWH training, but few offer formal didactics or a formal rotation.

A qualitative assessment of Ugandan women's perceptions and knowledge of contraception.

OBJECTIVE: To determine Ugandan women's perceptions and knowledge of contraception. METHODS: Healthy prepartum women were recruited from a national referral and university teaching hospital to participate in 1 of 5 focus group discussions on contraception. Transcripts were translated and coded by 2 researchers using inductive and deductive methods. RESULTS: Forty-six women participated in the focus group discussions. The major themes that emerged were around family planning as a method to space pregnancies and manage finances, as well as men's roles in decision making regarding contraception. Notable among the many incorrect notions about adverse effects of contraception were fears about cancer and infertility. CONCLUSION: The results indicate that, among the study group of Ugandan women, decision making regarding family planning involves a complex negotiation among women, partners, and families. Furthermore, pervasive myths may hinder a woman's ability to choose safe and effective contraception. These findings are useful to healthcare providers and the greater public-health community.