Physician perspectives on routine pregnancy intention screening and counseling in primary care.

OBJECTIVES: To assess factors associated with routine pregnancy intention screening by primary care physicians and their support for such an initiative. STUDY DESIGN: We conducted a cross-sectional survey study of 443 primary care physicians in New York State. We performed multivariable logistic regression analyses of physician support for routine pregnancy intention screening and implementation of screening in the last year. Predictors included in the models were physician age, sex, specialty, clinic setting, and, for the outcome of support for screening, experience with screening in the last year. RESULTS: In this convenience sample, the vast majority of respondents from all specialties (88%) felt pregnancy intention screening should be routinely included in primary care, with 48% reporting that they routinely perform such screening. The preferred wording for this question was one which assessed reproductive health service needs. In multivariable analyses, internal medicine physicians were less likely than family medicine physicians to have provided routine pregnancy intention screening (aOR = 0.15, 95% CI 0.09, 0.25). Only 8% of the sample reported they required more training to implement pregnancy intention screening, but more reported needing training prior to contraceptive provision (17%), contraceptive counseling (16%), and preconception care (15%). More internal medicine and other types of doctors cited a need for this additional training than family medicine physicians. CONCLUSIONS: Most responding primary care physicians supported routine integration of pregnancy intention screening. Incorporating additional training, especially for internal medicine physicians, in contraception and preconception care counseling is key to ensuring success. IMPLICATIONS STATEMENT: Responding primary care physicians supported routine inclusion of reproductive health needs assessment in primary care. Primary care may become increasingly important for ensuring access to a full range of reproductive health services. Providing necessary training, especially for internal medicine physicians, is needed prior to routine inclusion.

Trends in nonresident abortion rates in New York City from 2005 to 2015: a time series analysis.

OBJECTIVES: To examine trends and utilization patterns of NYC abortion services by nonresidents since growing abortion restrictions across many states could drive women to seek care in less restrictive jurisdictions including NYC. STUDY DESIGN: We used data from Induced Termination of Pregnancy certificates filed with the NYC Department of Health and Mental Hygiene in 2005-2015. An autoregressive integrated moving average (ARIMA) model was fit to the monthly nonresident abortion rate time series. Pearson's χ2 tests determined associations between women's residence and other variables. RESULTS: During 2005-2015, 885,816 abortions were reported in NYC, with 76,990 (8.7%) among nonresidents; 50,211 (65.2%) nonresidents lived in other New York State counties. The NYC abortion rate declined from 49.4 per 1000 women 15-44 in 2005 to 32.7 in 2015, while the nonresident rate showed minimal change from 0.12 per 1000 US women 15-44 in 2005 to 0.10 in 2015. ARIMA(0,1,1)(0,0,1) [12] fit the time series indicating minimal monthly changes in nonresident rates reflecting seasonal patterns and shorter-term dependencies between successive observations. Nonresidents differed from residents in all investigated variables including terminating at 20+ weeks (9.0% vs. 2.5%, p<.001) and having procedural methods (87.2% vs. 82.2%, p<.001). CONCLUSIONS: Nonresidents constituted few abortion patients in NYC with minimal change in nonresident rates in 2005-2015. Nonresidents more often sought later-term abortions and more complicated procedures posing greater associated costs/risks. Monitoring nonresident abortion trends and utilization patterns is valuable for planning local service delivery particularly in jurisdictions committed to providing comprehensive women's healthcare where nonresidents may increasingly seek abortions. IMPLICATIONS: While we found limited change in nonresident abortion rates in NYC in 2005-2015, other jurisdictions bordering more restrictive states could show different results and should consider conducting similar research. Such analyses are important in jurisdictions committed to providing comprehensive women's healthcare where nonresidents may increasingly seek abortions in the future.

Zika Virus Surveillance and Preparedness - New York City, 2015-2016.

Zika virus has rapidly spread through the World Health Organization's Region of the Americas since being identified in Brazil in early 2015. Transmitted primarily through the bite of infected Aedes species mosquitoes, Zika virus infection during pregnancy can cause spontaneous abortion and birth defects, including microcephaly (1,2). New York City (NYC) is home to a large number of persons who travel frequently to areas with active Zika virus transmission, including immigrants from these areas. In November 2015, the NYC Department of Health and Mental Hygiene (DOHMH) began developing and implementing plans for managing Zika virus and on February 1, 2016, activated its Incident Command System. During January 1-June 17, 2016, DOHMH coordinated diagnostic laboratory testing for 3,605 persons with travel-associated exposure, 182 (5.0%) of whom had confirmed Zika virus infection. Twenty (11.0%) confirmed patients were pregnant at the time of diagnosis. In addition, two cases of Zika virus-associated Guillain-Barré syndrome were diagnosed. DOHMH's response has focused on 1) identifying and diagnosing suspected cases; 2) educating the public and medical providers about Zika virus risks, transmission, and prevention strategies, particularly in areas with large populations of immigrants from areas with ongoing Zika virus transmission; 3) monitoring pregnant women with Zika virus infection and their fetuses and infants; 4) detecting local mosquito-borne transmission through both human and mosquito surveillance; and 5) modifying existing Culex mosquito control measures by targeting Aedes species of mosquitoes through the use of larvicides and adulticides.

Immediate postabortion access to IUDs, implants and DMPA reduces repeat pregnancy within 1 year in a New York City practice.

OBJECTIVE: The objective was to evaluate whether having intrauterine devices (IUDs), contraceptive implants and injections immediately available to women undergoing abortion, compared to requiring an additional visit for these methods, leads to fewer pregnancies and fewer abortions in the following 12 months. METHODS: We conducted a historical cohort study using health records of Medicaid-insured women obtaining a first-trimester surgical abortion within a single practice in New York City. Women in Cohort 1 (2007-2008) needed an additional visit to initiate the IUD or injection. Women in Cohort 2 (2008-2009) were able to initiate these contraceptives and implants during the abortion visit. Women in both cohorts received these methods without additional cost, and all could receive a pill, patch or ring prescription. We compared the proportions of each cohort who experienced a pregnancy that began in the 12 months following the index abortion and also evaluated the outcomes of those pregnancies. RESULTS: Cohorts 1 and 2 consisted of 407 and 405 women, respectively. The proportions with pregnancy beginning over the following 12 months were substantially greater in Cohort 1 than Cohort 2 (27.3% versus 15.3%, p<.001). Women in Cohort 1 then underwent both more additional abortions (17.2% versus 9.9%, p=.003) and more births (7.9% versus 3.7%, p=.02). The proportion of women in Cohort 1 who initiated IUDs and implants within 12 months was smaller than in Cohort 2 (11% versus 46%, p<.001). CONCLUSIONS: Among women insured by Medicaid, offering immediate comprehensive contraceptive access--including IUDs and implants--on the same day as an induced abortion, compared to requiring an additional visit, increased uptake of IUDs and implants and decreased repeat pregnancies in the next 12 months and abortions.

Structured contraceptive counseling--a randomized controlled trial.

OBJECTIVE: To evaluate the addition of structured contraceptive counseling to usual care on choice, initiation, and continuation of very effective contraception after uterine aspiration. METHODS: We conducted a RCT of a version of the WHO Decision-Making Tool for Family Planning Clients and Providers with women having a procedure for a spontaneous or induced abortion. Our intervention provided structured, standardized counseling. We randomized women to usual care or usual care with structured counseling. Our outcomes included choosing a very effective contraceptive method and 3 months continuation. RESULTS: Fifty-four percent of all participants chose a very effective method. Women in the intervention group were no more likely to choose a very effective method (OR 0.74, 95% CI 0.44, 1.26) or to initiate their method compared to the usual care group (OR 0.65, 95% CI 0.31, 1.34). In multivariate models, structured counseling was not associated with using a very effective method at 3 months (AOR 1.06, 95% CI 0.53, 2.14). CONCLUSION: In this setting, structured counseling had little impact on contraceptive method choice, initiation, or continuation. PRACTICE IMPLICATIONS: Adding structured counseling did not increase the proportion choosing or initiating very effective contraception in a practice setting where physicians already provide individualized counseling.

Emergency contraception: update and review.

Emergency contraception (EC) is the postcoital method of pregnancy prevention. Three methods of EC are used in the United States: (1) levonorgestrel-only pills, Plan B (Barr Pharmaceuticals, LLC, New Jersey) (2) combined estrogen and progestin pills, and (3) the copper intrauterine device. Used within 120 hours after unprotected sexual intercourse, EC reduces the risk of pregnancy by 60 to 94%. EC is a critical component of medical care for sexual assault survivors, and several states have laws mandating this standard of care. Levonorgestrel-only EC is available to women >or=17 years of age without a prescription. Women who were counseled by their clinician about EC were 11 times more likely to use EC in the following 12 months. Advance provision of EC to women has not been found to decrease rates of unintended pregnancy compared with routine pharmacy access; however, women routinely prefer advance provision. The newly approved by the Food and Drug Administration single-dose EC, Plan B One-Step (Barr Pharmaceuticals, LLC), may affect unintended pregnancy rates among EC users by simplifying use.