"It's Not a Top Priority": A Qualitative Analysis of Provider Views on Barriers to Reproductive Healthcare Provision for Homeless Women in the United States.

Women experiencing housing insecurity are at an elevated risk for adverse reproductive health outcomes due to the prevalence of chronic health conditions and higher risk behaviors. Social service and healthcare providers are front line in addressing women's needs when they seek support. Thus, we sought to explore reproductive healthcare barriers using in-depth interviews with 17 providers at 11 facilities serving housing-insecure women in Salt Lake County, Utah, USA from April to July 2018. Providers noted a number of system-, provider-, and individual-level barriers. Dominant themes include reliance on unstable funding, lack of provider training on reproductive health, and perceived logistical challenges to care. Due to the prevalence of immediate needs among housing-insecure women, providers attest that reproductive health needs often do not emerge as their urgent concern. Our findings suggest that addressing policy and funding challenges to prioritizing reproductive needs among housing-insecure women can help mitigate the potential for long-term adverse reproductive outcomes.

"For Me, It's Having Something Meaningful": Women's Emotional Understandings of Sex and the Sexual Acceptability of Contraception.

While the sexual acceptability of contraception - or, the impact of contraceptive methods on individuals' sexual experiences - is a growing area of research, less frequently do studies engage the importance of individual emotions around sex when it comes to perceptions of sexual acceptability. Building on Higgins and Smith's model of sexual acceptability and drawing upon insights from the sociology of gender, we used qualitative interview data with 30 women in Utah (USA) to explore the importance of emotional understandings of sex for women's assessments of the sexual acceptability of different contraceptives. Here we posit that emotional understandings of sex are not just individualistic - they are also structured by experiences with sexual partners and broader gendered expectations. This work adds insight into the importance of emotions in sexual acceptability and suggests the need for an amendment to Higgins and Smith's model that reflects the synergistic nature of the micro/individual, meso/interactional, and macro factors related to sexual acceptability. We conclude that assessing the sexual acceptability of contraceptives requires a nuanced multi-level interaction framework.

Reproductive autonomy and feelings of control over pregnancy among emerging adult clients in a Utah (USA) contraceptive initiative study.

OBJECTIVE: Research has called for more exploration into how reproductive autonomy (which includes agency over pregnancy decisions) is related to structural, relational, and individual elements. Thus, we use surveys to investigate how one potential indicator of reproductive autonomy-feelings of control over pregnancy-may relate to structural, relational, and individual factors in emerging adults' (age 18-24) lives. METHODS: Using survey data from 2594 emerging adult women participating in a contraceptive initiative in Utah (USA), we analyzed level of agreement with the statement: "I feel that I have control over whether or not I get pregnant," exploring relationships between sociodemographic characteristics and agreement with the statement. We used chi-square tests and multinomial logistic regression to investigate relationships between individual, relational, and structural factors and feelings of control. RESULTS: Most participants (86%) agreed with the statement (n = 2231), while the remainder were neutral or disagreed. Participants reporting poverty-level incomes (RRR: 1.80; 95 %CI 1.25-2.59) and previous unwanted pregnancies (RRR: 2.74; 95 %CI: 1.56-4.81) were more likely to describe "neutral" feelings of control. CONCLUSION: Findings indicate a relationship between feelings of control over pregnancy and several factors, and these results may help identify reproductive autonomy access gaps among emerging adults. More work should investigate these relationships as well as the meaning of "neutral" responses when it comes to assessments of control over pregnancy. TRIAL REGISTRATION: Clinicaltrials.gov identifier NCT02734199, Registered 12 April 2016.

Jail as a Point of Contraceptive Care Access: Needs and Preferences Among Women in an Urban Jail.

INTRODUCTION: Individuals who are incarcerated in the United States often struggle to access family planning care because of the common practice of jails not providing contraceptives on site. However, less is known about the contraceptive needs and preferences, including the desirability of intrauterine devices and implants, among those who are incarcerated. METHODS: Cross-sectional, in-person surveys were administered to 148 reproductive-age women (aged 18-48) incarcerated at an urban jail in Utah to identify women's contraceptive needs and preferences while incarcerated. We used summary statistics and logistic regression to investigate relationships between demographic characteristics, the desire to access contraceptive services while incarcerated, and interest in specific contraceptive methods. RESULTS: Surveys indicate a high interest in accessing contraceptives while in jail (73%). Participants who were more likely to prefer access to contraceptive services in jail were also more likely to be interested in the injectable (odds ratio [OR], 4.75; 95% CI, 1.03-21.94), the implant (OR, 8.44; 95% CI, 1.70-41.99), and intrauterine devices (OR, 10.04; 95% CI, 3.46-29.20) than participants indicating no desire to access contraceptive services while in jail. DISCUSSION: Jails could be an access point for contraceptive methods requiring health care provider intervention in the state of Utah. However, care must be taken due to broader historical legacies of reproductive coercion in carceral settings.

"I talked to a couple of friends that had it": Informal feminized health networks and contraceptive method choices.

Scholars recognize that social networks can influence a number of health behaviors, including women's contraceptive method choices. However, the gendered dynamics underlying the process of using non-medical information sources to make decisions about contraception has received less attention. Using 30 semi-structured interviews with women enrolled in a contraceptive initiative in the western United States, we explore how women use gendered understandings of medicine and feminized social networks to make decisions about contraceptives. Frequently categorizing their experiences in medical settings as unsatisfactory, women often turn to social support networks of other women-what we call "informal feminized health networks"-to gather information about the effects of contraceptives on women's bodies and to make decisions about which contraceptives are best. While informal feminized health networks are useful, women utilize them in light of unsatisfactory experiences in clinical settings. Working to uproot the paternalistic legacy of institutionalized medicine and improving provider-patient communication will enhance contraceptive access and help women reach their reproductive goals.

The HER Salt Lake media campaign: comparing characteristics and outcomes of clients who make appointments online versus standard scheduling.

BACKGROUND: Little research has examined how media outreach strategies affect the outcomes of contraceptive initiatives. Thus, this paper assesses the potential impact of an online media campaign introduced during the last six months of a contraceptive initiative study based in Salt Lake City, UT (USA). METHODS: During the last six months of the HER Salt Lake Contraceptive Initiative (September 2016-March 2017), we introduced an online media campaign designed to connect potential clients to information about the initiative and a brief (9-item) appointment request form (via HERsaltlake.org). Using linked data from the online form and electronic medical records, we examine differences in demographics, appointment show rates, and contraceptive choices between "online requester" clients who made clinical appointments through the online form (n = 356) and "standard requester" clients who made appointments using standard scheduling (n = 3,051). We used summary statistics and multivariable regression to compare groups. RESULTS: The campaign logged 1.7 million impressions and 15,765 clicks on advertisements leading to the campaign website (HERSaltLake.org). Compared to standard requesters, online requesters less frequently reported a past pregnancy and were more likely to be younger, white, and to enroll in the survey arm of the study. Relative to standard requesters and holding covariates constant, online requesters were more likely to select copper IUDs (RRR: 8.14), hormonal IUDs (RRR: 12.36), and implants (RRR: 10.75) over combined hormonal contraceptives (the contraceptive pill, patch, and ring). Uptake of the contraceptive injectable, condoms, and emergency contraception did not differ between groups. CONCLUSION: Clients demonstrating engagement with the media campaign had different demographic characteristics and outcomes than those using standard scheduling to arrange care. Online media campaigns can be useful for connecting clients with advertised contraceptive methods and initiatives. However, depending on design strategy, the use of media campaigns might shift the demographics and characteristics of clients who participate in contraceptive initiatives. TRIAL REGISTRATION: Clinicaltrials.gov identifier NCT02734199, Registered 12 April 2016-Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT02734199 .

Contraceptive Method Uptake at Title X Health Centers in Utah.

BACKGROUND: The Title X family planning program previously supported contraception for Utah clients with low incomes, yet its contributions may not have been sufficient to allow clients to select their preferred methods, including long-acting reversible contraceptives (LARCs). In this study, we compare the contraceptive method choices of self-paying clients with low incomes at three participating Title X health centers in Salt Lake County, Utah, before and after the removal of additional cost barriers. METHODS: We used retrospective medical record review to assess clients' contraceptive choices during two 6-month periods: a control period with Title X-assisted sliding scale payment schedules (n = 2,776) and an intervention period offering no-cost contraceptive care (n = 2,065). We used logistic regression to identify the likelihood of selecting a LARC during the intervention period and multinomial regression to identify the selection probability of different types of available LARCs. RESULTS: During the control period, 16% of participants chose a LARC compared with 26% in the intervention period (p ≤ .001). During the intervention period, participants were 1.8 times more likely to select LARCs (95% confidence interval, 1.65-2.13) compared with non-LARC methods, holding covariates constant. In the multinomial regression, participants were three times more likely during the intervention period to select an implant than a pill, patch, or ring, holding all other covariates constant (odds ratio, 3.08; 95% confidence interval, 2.47-3.83). CONCLUSIONS: Title X clients offered contraceptive methods without cost more frequently selected a LARC method. Title X funding reductions may impede individuals' access to their contraceptive methods of choice.

Conflicting contraceptive norms for men: equal responsibility versus women's bodily autonomy.

Most research investigating how men and women in heterosexual relationships negotiate contraceptive use focuses on the women's point of view. Using a sample of 44 interviews with men attending a western US university, this study examines norms governing men's participation in contraceptive use and pregnancy prevention and their responses to those norms. The paper demonstrates how competing norms around sexual health decision-making and women's bodily autonomy contribute to unintended outcomes that undermine young people's quest for egalitarian sexual relationships. While men largely agree that responsibility for sexual health decision-making should be shared with women, they also believe that women should have power over their own bodies and sexual health. However, the coexistence of these two competing norms - which call for both equal responsibility in decision-making and women's bodily autonomy - results in a disconnect between men saying that sexual health decision-making should be equal, but not always participating equally. Thus, men largely give contraceptive decision-making power over to women, putting the burden of pregnancy prevention onto women and letting men off the hook. It is concluded that men's negotiation of these competing norms reinforces unequal power and inequality in sexual relationships.