Perinatal Mood And Anxiety Disorders Rose Among Privately Insured People, 2008-20.

Nationwide, perinatal mood and anxiety disorder (PMAD) diagnoses among privately insured people increased by 93.3 percent from 2008 to 2020, growing faster in 2015-20 than in 2008-14. Most states and demographic subgroups experienced increases, suggesting worsening morbidity in maternal mental health nationwide. PMAD-associated suicidality and psychotherapy rates also increased nationwide from 2008 to 2020. Relative to 2008-14, psychotherapy rates continued to rise in 2015-20, whereas suicidality rates declined.

Reasons for past abortions among women in treatment for opioid use disorder.

OBJECTIVE: The main reasons women in the general population seek abortion are financial, timing, and partner-related reasons. While women with opioid use disorder (OUD) appear to use abortion services more than women in the general population, reasons for abortion in this group have not been examined to our knowledge. METHOD: Female patients aged 18-50 years in OUD treatment at 22 randomly selected facilities in Michigan were surveyed. The survey included items assessing reproductive health history. Women who reported having one or more abortions were asked to think back to that time and their reasons for choosing abortion. Twenty potential reasons and a write-in option were offered; women could endorse as many as applied. RESULTS: Of 260 women surveyed, 84 reported having an abortion. Of these, most (77.4%) reported multiple reasons for having an abortion. The most common reasons for having an abortion were not having money to take care of a baby (54.8%), feeling too young to have a child and not feeling ready to be a mother (both 42.9%), not loving the father and other partner-related concerns (25.0%-32.1%), and having concerns about the effects of their drug use (28.6%). No combination of reasons for abortion emerged as more prevalent than any other. CONCLUSIONS: Like women in the general population, women in treatment for OUD had not only abortions because of financial, timing, and partner-related reasons but also concerns about the effects of their drug use. These results underscore the multiple and often interrelated reasons that lead women to seek abortion. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Mystery Shopper Study of State Medicaid Coverage for Out-of-State Abortion Care.

This cross-sectional study uses a mystery shopper survey to examine variation in state Medicaid agency responses to coverage questions on out-of-state abortion care.

Association of the Mental Health Parity and Addiction Equity Act and the Affordable Care Act on severe maternal morbidity.

OBJECTIVE: This study aimed to characterize the association between Mental Health Parity and the Affordable Care Act and rates of severe maternal morbidity among a population of commercially insured individuals, including individuals with and without perinatal mood and anxiety disorders. METHODS: We conducted a serial, cross-sectional analysis of individuals with an inpatient delivery in Optum's Clinformatics® Data Mart Database from 2008 to 2021. We applied an interrupted time series model with autoregressive integrated moving average to evaluate changes in quarterly severe maternal morbidity rates. RESULTS: Adjusted severe maternal morbidity rates declined from 167.2 (95%CI: [152.6, 181.9]) per 10,000 deliveries in the first quarter of 2008 to 98.2 (95%CI: [83.5, 112.8]) per 10,000 deliveries in the last quarter of 2021. Severe maternal morbidity rates remained higher, but declined to a greater degree, among those with perinatal mood and anxiety disorders (435.6, 95%CI: [379.9, 491.3], to 165.0, 95%CI: [109.3, 220.8] per 10,000 deliveries) compared to those without (153.0, 95%CI: [140.7, 165.3] to 81.8, 95%CI: [69.6, 94.1] per 10,000 deliveries). CONCLUSION: The observed association suggests implementation of Mental Health Parity and Affordable Care Act may have played a role in lowering rates of severe maternal morbidity, particularly among individuals with perinatal mood and anxiety disorders.

Tubal Sterilization Requests at a Single Institution Following the Supreme Court Decision to Overturn the Constitutional Right to Abortion.

This study uses data from electronic health records to examine the rate of tubal sterilization requests in 3 periods before and after the US Supreme Court's 2022 Dobbs v Jackson Women's Health Organization decision, compared with the same periods in 2019 and 2021, at a single institution in Michigan.

Trends in chronic pain conditions among delivering women with and without mood and anxiety disorders.

OBJECTIVE: The co-existence of chronic pain conditions with anxiety and/or depression is common in the general population but poorly described during pregnancy. In this study, we sought to describe trends in chronic pain among a sample of delivering people and describe the co-existence of chronic pain with anxiety and/or depression among delivering people. METHODS: This cross-sectional study used data from Optum's de-identified Clinformatics® Data Mart Database between 2008 and 2021, for delivering persons with coverage by single employer-based health plan. We computed predicted margins from generalized estimating equations to determine the marginal predicted probability of chronic pain among all delivering and non-delivering persons who identify as women with and without diagnosed anxiety and/or depression. RESULTS: Musculoskeletal and pelvic pain occurred most often regardless of delivering status. Delivering persons with anxiety and/or depression had higher marginal predicted probabilities of chronic pain compared to all delivering persons. Between 2008 and 2021, the predicted probabilities ranged from 0.400 to 0.527 and 0.221-0.261, respectively. CONCLUSION: Chronic pain conditions are common in pregnancy and nearly two times higher among individuals with anxiety and/or depression. The frequency of comorbid depression and/or anxiety with pain disorders among delivering persons highlights the importance of proper detection, coordination of care, and safe treatment options for this population.

Pregnancy Outcomes in a US Cohort of Transgender People.

This study assesses severe parental morbidity, cesarean deliveries, and preterm births among commercially and publicly insured trans people compared with cisgender people.

The potential impact of neighboring states' bans on abortion volume in a haven state.

OBJECTIVES: We explored the potential impact of abortion bans in neighboring states on Michigan's abortion volume. STUDY DESIGN: Using ArcGIS mapping software, we determined which counties in neighboring states had their closest out-of-state abortion clinic in Michigan. We estimated the change in abortions in Michigan occurring from neighboring states' residents, assuming complete bans in those states. RESULTS: Complete bans in neighboring states could increase abortion volume in Michigan by approximately 5928 out-of-state patients annually (21% increase). CONCLUSIONS: Complete bans in neighboring states may markedly increase abortions occurring in Michigan, which may strain Michigan facilities' capacity to provide abortion care.

Determining the Sex Assigned at Birth of Transgender and Nonbinary Populations in Administrative Claims Databases Utilizing Diagnostic and Procedure Codes.

Purpose: Widespread conflation of sex assigned at birth and gender has hindered the identification of transgender and nonbinary people in large datasets. The study objective was to develop a method of determining the sex assigned at birth of transgender and nonbinary patients utilizing sex-specific diagnostic and procedural codes, for future use in administrative claims databases, with a goal of expanding the available datasets for exploring sex-specific conditions among transgender and nonbinary people. Methods: Authors reviewed indexes of International Classification of Diseases (ICD) and Current Procedural Terminology (CPT) codes, and medical record data from a single institution's gender-affirming clinics. Sex-specific ICD and CPT codes were identified through author review and consultation with subject experts. Patient's sex assigned at birth determined by chart review, as a gold standard, was compared with sex assigned at birth determined by querying their electronic health records for natal sex-specific codes. Results: Sex-specific codes correctly identified 53.5% (n=364) of transgender and nonbinary patients assigned female sex at birth, and 17.3% (n=108) of those assigned male sex at birth. Codes were 95.7% and 98.3% specific for assigned female and male sex at birth, respectively. Conclusions: ICD and CPT codes can be used to specifically determine the sex assigned at birth in databases where this information is not recorded. This methodology has novel potential for use in exploring sex-specific conditions among transgender and nonbinary patients in administrative claims data.

Early Pregnancy Loss Management in the Emergency Department vs Outpatient Setting.

Importance: Early pregnancy loss (EPL), or miscarriage, is the most common complication of early pregnancy, and many patients experiencing EPL present to the emergency department (ED). Little is known about how patients who present to the ED with EPL differ from those who present to outpatient clinics and how their management and outcomes differ. Objective: To compare the management and outcomes of patients with EPL who present to the ED vs outpatient clinics. Design, Setting, and Participants: This retrospective cohort study used the IBM MarketScan Research Database, a national insurance claims database. Participants were pregnant people aged 15 to 49 years in the US who presented to either an ED or outpatient clinic for initial diagnosis of EPL from October 2015 through December 2019. Data analysis was performed from May 2021 to March 2022. Exposures: The primary exposure was location of service (ED vs outpatient clinic). Other exposures of interest included demographic characteristics, current pregnancy history, and comorbidities. Main Outcomes and Measures: The primary outcome was EPL management type (surgical, medication, or expectant management). Complications, including blood transfusion and hospitalization, and characteristics associated with location of service were also evaluated. Bivariable analyses and multivariable logistic regression were used for data analysis. Results: A total of 117 749 patients with EPL diagnoses were identified, with a mean (SD) age of 31.8 (6.1) years. Of these patients, 20 826 (17.7%) initially presented to the ED, and 96 923 (82.3%) presented to outpatient clinics. Compared with the outpatient setting, patients in the ED were less likely to receive surgical (2925 patients [14.0%] vs 23 588 patients [24.3%]) or medication (1116 patients [5.4%] vs 10 878 patients [11.2%]) management. In the adjusted analysis, characteristics associated with decreased odds of active (surgical or medication) vs expectant management included ED (vs outpatient) presentation (adjusted odds ratio [aOR], 0.46; 95% CI, 0.44-0.47), urban location (aOR, 0.87; 95% CI, 0.82-0.91), and being a dependent on an insurance policy (vs primary policy holder) (aOR, 0.71; 95% CI, 0.67-0.74); whereas older age (aOR per 1-year increase 1.01; 95% CI, 1.01-1.01), established prenatal care (aOR, 2.35; 95% CI, 2.29-2.42), and medical comorbidities (aOR, 1.05; 95% CI, 1.02-1.09) were associated with increased odds of receiving active management. Patients in the ED were more likely than those in outpatient clinics to need a blood transfusion (287 patients [1.4%] vs 202 patients [0.2%]) or hospitalization (463 patients [2.2%] vs 472 patients [0.5%]), but complications were low regardless of location of service. Conclusions and Relevance: In this cohort study of privately insured patients with EPL, differences in management between the ED vs outpatient setting may reflect barriers to accessing comprehensive EPL management options. More research is needed to understand these significant differences in management approaches by practice setting, and to what extent EPL management reflects patient preferences in both outpatient and ED settings.

Developing an Adjunct Services Approach to Identify the Use of Procedures Not Covered by Health Insurance: The Case of In Vitro Fertilization.

BACKGROUND: Health care claims have an inherent limitation in that noncovered services are unreported. This limitation is particularly problematic when researchers wish to study the effects of changes in the insurance coverage of a service. In prior work, we studied the change in the use of in vitro fertilization (IVF) after an employer added coverage. To estimate IVF use before coverage began, we developed and tested an Adjunct Services Approach that identified patterns of covered services cooccurring with IVF. METHODS: Based on clinical expertise and guidelines, we developed a list of candidate adjunct services and used claims data after IVF coverage began to assess associations of those codes with known IVF cycles and whether any additional codes were also strongly associated with IVF. The algorithm was validated by primary chart review and was then used to infer IVF in the precoverage period. RESULTS: The selected algorithm included pelvic ultrasounds and either menotropin or ganirelix, yielding a sensitivity of 93.0% and specificity of >99.9%. DISCUSSION: The Adjunct Services Approach effectively assessed the change in IVF use postinsurance coverage. Our approach can be adapted to study IVF in other settings or to study other medical services experiencing coverage changes (eg, fertility preservation, bariatric surgery, and sex confirmation surgery). Overall, we find that an Adjunct Services Approach can be useful when (1) clinical pathways exist to define services delivered adjunct to the noncovered service, (2) those pathways are followed for most patients receiving the service, and (3) similar patterns of adjunct services occur infrequently with other procedures.

Give women what they want: contraceptive discontinuation and method preference in urban Ghana.

BACKGROUND: Unmet need for contraception remains high in Ghana. Reducing the number of women who discontinue their contraceptive use is one way to decrease the number of women with an unmet need. In this study, we investigated factors associated with discontinuation among a cohort of Ghanaian women. METHODS: Women who were beginning a new method of contraception at one of six urban clinics in Accra and Kumasi, Ghana were invited to participate in our study. Participants were interviewed before and after their counseling session, and at 3-, 6-, 9-, and 12-months post-enrollment to determine continuation. During follow-up, participants who were no longer using their method were asked why, if they were using any method of contraception, and if so, which method. Logistic regression analysis was performed to identify factors associated with discontinuation for reason other than pregnancy or desired pregnancy. RESULTS: Of the 472 women who reported leaving their counseling session with a method, 440 (93.2%) had at least one follow-up contact. Of the 440 women, 110 (25%) discontinued their method at some point over the 12-month period, and 94 (85.5%) did so for reasons other than pregnancy or desired pregnancy. In the multivariate regression analysis, women who reported they were given their method of choice were 12.0% less likely to discontinue due to a non-pregnancy reason (p=0.005); those who used a long-acting reversible contraceptive (LARC) method were 11.1% less likely (p=.001); and those who reported they would choose to use that method again, one measure of satisfaction, were 23.4% less likely (p<.001). CONCLUSIONS: To our knowledge, the current study is the first to explore method preference and its relation to continuation. Women in our study who reported they were given the contraceptive method of their choice were less likely to discontinue using that method for non-pregnancy-related reasons. Further, those who adopted a LARC method and those who reported they would make the same method choice again were less likely to discontinue. Women should be supported in selecting a contraceptive method of their choice. Providers should work with their clients to find a method which meets their preferences.

Experiences With Prenatal Care Delivery Reported by Black Patients With Low Income and by Health Care Workers in the US: A Qualitative Study.

Importance: Black pregnant people with low income face inequities in health care access and outcomes in the US, yet their voices have been largely absent from redesigning prenatal care. Objective: To examine patients' and health care workers' experiences with prenatal care delivery in a largely low-income Black population to inform care innovations to improve care coordination, access, quality, and outcomes. Design, Setting, and Participants: For this qualitative study, human-centered design-informed interviews were conducted at prenatal care clinics with 19 low-income Black patients who were currently pregnant or up to 1 year post partum and 19 health care workers (eg, physicians, nurses, and community health workers) in Detroit, Michigan, between October 14, 2019, and February 7, 2020. Questions focused on 2 human-centered design phases: observation (understanding problems from the end user's perspective) and ideation (generating novel potential solutions). Questions targeted participants' experiences with the 3 goals of prenatal care: medical care, anticipatory guidance, and social support. An eclectic analytic strategy, including inductive thematic analysis and matrix coding, was used to identify promising strategies for prenatal care redesign. Main Outcomes and Measures: Preferences for prenatal care redesign. Results: Nineteen Black patients (mean [SD] age, 28.4 [5.9] years; 19 [100%] female; and 17 [89.5%] with public insurance) and 17 of 19 health care workers (mean [SD] age, 47.9 [15.7] years; 15 female [88.2%]; and 13 [76.5%] Black) completed the surveys. A range of health care workers were included (eg, physicians, doulas, and social workers). Although all affirmed the 3 prenatal care goals, participants reported failures and potential solutions for each area of prenatal care delivery. Themes also emerged in 2 cross-cutting areas: practitioners and care infrastructure. Participants reported that, ideally, care structure would enable strong ongoing relationships between patients and practitioners. Practitioners would coordinate all prenatal services, not just medical care. Finally, care would be tailored to individual patients by using care navigators, flexible models, and colocation of services to reduce barriers. Conclusions and Relevance: In this qualitative study of low-income, Black pregnant people in Detroit, Michigan, and the health care workers who care for them, prenatal care delivery failed to meet many patients' needs. Participants reported that an ideal care delivery model would include comprehensive, integrated services across the health care system, expanding beyond medical care to also include patients' social needs and preferences.

Stigma and Reproductive Health Service Access Among Women in Treatment for Substance Use Disorder.

OBJECTIVE: We aimed to examine the role of perceived and direct stigma on access to reproductive health services among women in treatment for substance use disorders in Michigan. METHODS: We draw on self-interview data from a cross-sectional study of female patients aged 18-50 years who accessed substance use disorder treatment at 22 randomly selected facilities in Michigan from December 2015 to May 2017. We conducted logistic regressions to examine associations between perceived stigma and access to three types of reproductive health services (screening exams, birth control, and prenatal care), as well as direct stigma and access to birth control. RESULTS: The final sample included 260 women. A notable percentage of women reported inability to access reproductive health services (24% for screening exams, 14% for birth control, and 12% for prenatal care). Women with higher levels of perceived stigma because of substance use were significantly more likely to report inability to access screening exams (odds ratio [OR]: 2.14; confidence interval [CI]: 1.43-3.20) and birth control (OR: 2.17; CI: 1.36-3.77). Women reporting higher levels of direct stigma were also significantly more likely to report inability to access birth control (OR: 3.87; CI: 2.29-6.53), even after accounting for perceived stigma. CONCLUSION: Perceived and direct stigma because of substance use may be significant barriers to seeking and accessing reproductive health services for women. Health professionals should reduce stigma in health care in order to increase access to necessary services for this population.

Postpartum depression and associated risk factors during the COVID-19 pandemic.

OBJECTIVE: To describe postpartum depression and associated risk factors among postpartum patients in the United States (US) between February and July 2020. This study used a cross-sectional descriptive design to collect survey data from a convenience sample of postpartum patients who lived in the US and delivered a live infant after the US declared COVID-19 a public health emergency. RESULTS: Our sample included 670 postpartum patients who completed an online survey inclusive of the Edinburgh Postnatal Depression Scale (EPDS) and selected demographic items (e.g. NICU admission status, infant gestational age, infant feeding method). In our sample, 1 in 3 participants screened positive for postpartum depression and 1 in 5 had major depressive symptoms. Participants who fed their infants formula had 92% greater odds of screening positive for postpartum depression and were 73% more likely to screen positive for major depressive symptoms compared to those who breastfed or bottle-fed with their own human milk. Participants with infants admitted to a NICU had 74% greater odds of screening positive. Each 1 week increase in weeks postpartum increased the odds of screening positive by 4%. Participants who worried about themselves and their infants contracting COVID-19 had 71% greater odds of screening positive.

Leveraging Administrative Claims to Understand Disparities in Gender Minority Health: Contraceptive Use Patterns Among Transgender and Nonbinary People.

Purpose: Transgender people face disparities in access to reproductive and sexual health services; however, differences in receipt of contraceptive services have not been quantified. We compare contraceptive patterns between cisgender women and trans masculine people in insurance claims databases. Methods: We analyzed 2014-2018 Truven MarketScan data, using diagnostic and procedural codes to identify sex assigned at birth, and existing coding methodology to identify transgender and nonbinary people. We compared contraceptive patterns between cisgender women and trans masculine people aged 15-49 in Medicaid and commercial databases. Results: We identified 4700 people in the commercial and 1628 people in the Medicaid databases as trans masculine. Trans masculine people were prescribed fewer oral contraceptive pills (Medicaid: 17.44%, commercial: 16.62%) compared to cisgender women (Medicaid: 24.96%, commercial: 27.85%), less long-acting reversible contraception (LARC) use (Medicaid: 7.62%, commercial: 7.49% vs. Medicaid: 12.79%, commercial: 8.51%), had more hysterectomies (Medicaid: 5.77%, commercial: 8.45% vs. Medicaid: 2.15%, commercial: 2.48%), and less evidence of any contraception (Medicaid: 34.21%, commercial: 32.28% vs. Medicaid: 46.80%, commercial: 39.81%). Hysterectomies and LARC use varied by insurance type. Conclusion: We found significant differences in contraceptive patterns between trans masculine people and cisgender women. Data suggest potential differences in hysterectomy occurrences by trans masculine people, and long-acting reversible contraceptive use by cisgender women, in Medicaid versus commercial insurance cohorts. Appropriate counseling, insurance coverage, and removal of structural barriers are needed to ensure adequate access to contraception methods for people of all genders-regardless of whether they are being employed for contraception, menstrual management, or gender affirmation.

"Mourning the Experience of What Should Have Been": Experiences of Peripartum Women During the COVID-19 Pandemic.

OBJECTIVES: The ongoing COVID-19 pandemic may significantly affect the peripartum experience; however, little is known about the perceptions of women who gave birth during the COVID-19 pandemic. Thus, the purpose of our study was to describe the peripartum experiences of women who gave birth during the COVID-19 pandemic in the United States. METHODS: Using a cross-sectional design, we collected survey data from a convenience sample of postpartum women recruited through social media. Participants were 18 years of age or older, lived in the United States, gave birth after February 1, 2020, and could read English. This study was part of the COVID-19 Maternal Attachment, Mood, Ability, and Support study, which was a larger study that collected survey data describing maternal mental health and breastfeeding during the COVID-19 pandemic. This paper presents findings from the two free-text items describing peripartum experiences. Using the constant comparative method, responses were thematically analyzed to identify and collate major and minor themes. RESULTS: 371 participants responded to at least one free-text item. Five major themes emerged: (1) Heightened emotional distress; (2) Adverse breastfeeding experiences; (3) Unanticipated hospital policy changes shifted birthing plans; (4) Expectation vs. reality: "mourning what the experience should have been;" and (5) Surprising benefits of the COVID-19 pandemic to the delivery and postpartum experience. CONCLUSIONS FOR PRACTICE: Peripartum women are vulnerable to heightened stress induced by COVID-19 pandemic sequalae. During public health crises, peripartum women may need additional resources and support to improve their mental health, wellbeing, and breastfeeding experiences.