The end of Roe v. Wade: implications for Women's mental health and care.

The Supreme Court decision in Dobbs v. Jackson in June 2022 reversed precedent which had previously protected abortion prior to fetal viability as a universal right within the United States. This decision almost immediately led to abortion restrictions across 25 states. The resulting lack of access to abortion care for millions of pregnant people will have profound physical and mental health consequences, the full effects of which will not be realized for years to come. Approximately 1 in 5 women access abortions in the U.S. each year. These women are diverse and represent all American groups. The Supreme court decision, however, will affect populations that have and continue to be marginalized the most. Forcing pregnant individuals to carry unwanted pregnancies worsens health outcomes and mortality risk for both the perinatal individual and the offspring. The US has one of the highest maternal mortality rates and this rate is projected to increase with abortion bans. Abortion policies also interfere with appropriate medical care of pregnant people leading to less safe pregnancies for all. Beyond the physical morbidity, the psychological sequelae of carrying a forced pregnancy to term will lead to an even greater burden of maternal mental illness, exacerbating the already existing maternal mental health crisis. This perspective piece reviews the current evidence of abortion denial on women's mental health and care. Based on the current evidence, we discuss the clinical, educational, societal, research, and policy implications of the Dobbs v. Jackson Supreme Court decision.

Health Equity Morbidity and Mortality Conferences in Obstetrics and Gynecology.

Maternal mortality and morbidity continue to occur at unacceptably high levels in the United States, with communities of color experiencing significantly higher rates than their White counterparts, even after adjustment for confounding factors such as socioeconomic status. Many obstetrics and gynecology departments across the country have begun to incorporate routine discussion and analysis of health equity into peer review and educational processes, including grand rounds and morbidity and mortality conferences. Despite the desire and drive, there is little published guidance on best practices for incorporation of an equity component into these conferences. This document outlines the current processes at four academic institutions to highlight the variety of ways in which health equity and social justice can be incorporated when analyzing patient experiences and health outcomes. This commentary also provides a list of specific recommendations based on the combined experiences at these institutions so that others across the country can incorporate principles of health equity into their peer-review processes.

Pain Management for Gynecologic Procedures in the Office.

IMPORTANCE: Satisfactory pain control for women undergoing office gynecologic procedures is critical for both patient comfort and procedure success. Therefore, it is important for clinicians to be aware of the safety and efficacy of different pain control regimens. OBJECTIVE: This article aimed to review the literature regarding pain control regimens for procedures such as endometrial biopsy, intrauterine device insertion, colposcopy and loop electrosurgical excisional procedure, uterine aspiration, and hysteroscopy. EVIDENCE ACQUISITION: A search of published literature using PubMed was conducted using the following keywords: "pain" or "anesthesia." These terms were paired with the following keywords: "intrauterine device" or "IUD," "endometrial biopsy," "uterine aspiration" or "abortion," "colposcopy" or "loop electrosurgical excisional procedure" or "LEEP," "hysteroscopy" or "hysteroscopic sterilization." The search was conducted through July 2015. Articles were hand reviewed and selected by the authors for study quality. Meta-analyses and randomized controlled trials were prioritized. RESULTS: Although local anesthesia is commonly used for gynecologic procedures, a multimodal approach may be more effective including oral medication, a dedicated emotional support person, and visual or auditory distraction. Women who are nulliparous, are postmenopausal, have a history of dysmenorrhea, or suffer from anxiety are more likely to experience greater pain with gynecologic procedures. Evidence for some interventions exists; however, the interpretation of intervention comparisons is limited by the use of different regimens, pain measurement scales, patient populations, and procedure techniques. CONCLUSIONS AND RELEVANCE: There are many options for pain management for office gynecologic procedures, and depending on the procedure, different modalities may work best. The importance of patient counseling and selection cannot be overstated.

Medical Compared With Surgical Abortion for Effective Pregnancy Termination in the First Trimester.

OBJECTIVE: To compare efficacy between medical and surgical abortion at 9 weeks of gestation or less. METHODS: We performed a retrospective cohort study comparing efficacy of medical compared with surgical abortion before 64 days of gestation at Planned Parenthood, Los Angeles, from November 2010 to August 2013. Electronic medical records were reviewed for ongoing pregnancies after the initial abortion procedure. Data were also collected on complications occurring within the immediate postabortal period (8 weeks postabortal) including unanticipated aspiration and major adverse events (emergency department presentation, hospitalization, perforation, transfusion, infection). Chi square test and logistic regression were used to compare the primary outcomes between cohorts. RESULTS: Data were collected from 30,146 women with pregnancies seeking termination before 64 days of gestation. Sociodemographic and clinical characteristics were similar in the medication and surgical abortion groups. Efficacy of pregnancy termination was 99.6% for medication abortions and 99.8%% for surgical abortions (P<.001). The medication abortion group was more likely to undergo an unanticipated aspiration, for ongoing pregnancy or persistent pain, bleeding, or both (2.1% compared with 0.6%, respectively, odds ratio 1.6, 95% confidence interval 1.1-2.3). These rates were unchanged after controlling for gravidity, parity, and body mass index. There was no difference in major adverse events between the two groups. CONCLUSION: Medication abortion and surgical abortion before 64 days of gestation are both highly effective with low complication rates. LEVEL OF EVIDENCE: II.

The effect of immediate postpartum compared to delayed postpartum and interval etonogestrel contraceptive implant insertion on removal rates for bleeding.

OBJECTIVE: To determine whether the discontinuation rate of the etonogestrel contraceptive implant due to irregular vaginal bleeding among women with immediate postpartum insertion is increased compared to delayed postpartum and interval placement. STUDY DESIGN: This retrospective cohort study compared women who underwent immediate postpartum etonogestrel contraceptive implant insertion (within 96 h of delivery) to delayed postpartum (6 to 12 weeks postpartum) and interval insertion between January 2008 and December 2010. Charts were reviewed for date and reason for removal. A chi-squared test was used to compare discontinuation due to bleeding between cohorts. Baseline characteristics predictive of implant removal were evaluated by simple logistic regression. RESULTS: There were 259 women in the immediate postpartum group, 49 in the delayed postpartum group and 106 in the interval group. Average age at insertion was 22.6 (±5.5) years. Overall, 19.3% of women in the immediate postpartum group requested removal due to irregular bleeding compared to 18.4% in the delayed postpartum group [odds ratio (OR) 1.06, 95% confidence interval (CI) 0.48-2.33] and 20.8% in the interval group (OR 0.91, 95% CI 0.52-1.60). There was no difference between groups in premature removal rates for any side effect. There were no sociodemographic or clinical characteristics predictive of removal in any group. CONCLUSION: One-fifth of etonogestrel contraceptive implant users requested premature removal due to irregular bleeding. Immediate postpartum implant insertion does not lead to increased removal rates and may help reduce unintended pregnancy. Mechanisms to help women manage irregular bleeding due to the implant are needed. IMPLICATIONS: Immediate postpartum insertion of the etonogestrel contraceptive implant does not lead to increased removal rates due to vaginal bleeding compared to delayed postpartum or interval insertion. Immediate postpartum implant insertion may increase uptake of long-acting reversible contraception and help reduce short interpregnancy intervals and unintended pregnancy.