Assessing contraceptive use as a continuum: outcomes of a qualitative assessment of the contraceptive journey.

BACKGROUND: Contraceptive use is often a multi-decade experience for people who can become pregnant, yet few studies have assessed how this ongoing process impacts contraceptive decision-making in the context of the reproductive life course. METHODS: We conducted in-depth interviews assessing the contraceptive journeys of 33 reproductive-aged people who had previously received no-cost contraception through a contraceptive initiative in Utah. We coded these interviews using modified grounded theory. RESULTS: A person's contraceptive journey occurred in four phases: identification of need, method initiation, method use, and method discontinuation. Within these phases, there were five main areas of decisional influence: physiological factors, values, experiences, circumstances, and relationships. Participant stories demonstrated the ongoing and complex process of navigating contraception across these ever-changing aspects. Individuals stressed the lack of any "right" method of contraception in decision-making and advised healthcare providers to approach contraceptive conversations and provision from positions of method neutrality and whole-person perspectives. CONCLUSIONS: Contraception is a unique health intervention that requires ongoing decision-making without a particular "right" answer. As such, change over time is normal, more method options are needed, and contraceptive counseling should account for a person's contraceptive journey.

Distance Traveled for Abortion at a North Carolina Tertiary Care Center Following Restrictive Legislation.

Background: North Carolina enacted 5 statutes restricting abortion between 2011 and 2016. Our objective was to compare the proportion of women who traveled more than 25 miles to a Southern tertiary care center during 2 distinct time periods (2011 and 2017). Methods: We conducted a time-series retrospective cohort study of women who obtained an abortion at University of North Carolina hos-pitals in 2011 and 2017. We collected data regarding residence, demographics, gestational age, indication, parity, and referral source. Our primary outcome was distance traveled from a person's residence to the study center. Results: We enrolled 399 women, 139 in 2011 and 260 in 2017. In 2011, 72% (100 of 139) traveled more than 25 miles, compared with 75% (195 of 260) in 2017. Fewer women traveled greater than 100 miles from their residence to our clinic in 2011 (20%) compared to 2017 (26%). Fewer women from neighboring states were seen in 2011 than 2017 (p = .04). Women seeking abortion in 2011 were 4 times less likely to have been referred from a freestanding abortion clinic compared with women in 2017 (9% [13 of 139] versus 37% [96 of 260]). Limitations: The tertiary referral nature of our study limits generalizability. With 2 time-distinct cohorts, there may be factors that changed over the study period that remain unaccounted for. Conclusions: A similar proportion of women traveled more than 25 miles for abortion before and after the legislative changes. Our finding that more women traveled greater than 100 miles to obtain an abortion in 2017 compared to 2011 highlights a key burden to abortion ac-cess in North Carolina. The increased number of women seen from freestanding abortion centers and from neighboring states following the legislative changes highlights an important geographical burden potentially associated with strict abortion restrictions.

Maternal near-miss surveillance, Namibia.

OBJECTIVE: To analyse and improve the Namibian maternity care system by implementing maternal near-miss surveillance during 1 October 2018 and 31 March 2019, and identifying the challenges and benefits of such data collection. METHODS: From the results of an initial feasibility study, we adapted the World Health Organization's criteria defining a maternal near miss to the Namibian health-care system. We visited most (27 out of 35) participating facilities before implementation and provided training on maternal near-miss identification and data collection. We visited all facilities at the end of the surveillance period to verify recorded data and to give staff the opportunity to provide feedback. FINDINGS: During the 6-month period, we recorded 37 106 live births, 298 maternal near misses (8.0 per 1000 live births) and 23 maternal deaths (62.0 per 100 000 live births). We observed that obstetric haemorrhage and hypertensive disorders were the most common causes of maternal near misses (each 92/298; 30.9%). Of the 49 maternal near misses due to pregnancies with abortive outcomes, ectopic pregnancy was the most common cause (36/298; 12.1%). Fetal or neonatal outcomes were poor; only 50.3% (157/312) of the infants born to maternal near-miss mothers went home with their mother. CONCLUSION: Maternal near-miss surveillance is a useful intervention to identify within-country challenges, such as lack of access to caesarean section or hysterectomy. Knowledge of these challenges can be used by policy-makers and programme managers in the development of locally tailored targeted interventions to improve maternal outcome in their setting.

Freshwater Viromes: From Sampling to Evaluation.

There are a number of options available to researchers who wish to collect and analyze viral metagenomes (viromes) from environmental samples. Here we describe a laboratory procedure for generation of viromes from freshwater samples, specifically targeting dsDNA bacteriophages. We also discuss methods for bioinformatic analysis of the resulting data.