Estimates of use of preferred contraceptive method in the United States: a population-based study.

Background: In the U.S. and globally, dominant metrics of contraceptive access focus on the use of certain contraceptive methods and do not address self-defined need for contraception; therefore, these metrics fail to attend to person-centeredness, a key component of healthcare quality. This study addresses this gap by presenting new data from the U.S. on preferred contraceptive method use, a person-centered contraceptive access indicator. Additionally, we examine the association between key aspects of person-centered healthcare access and preferred contraceptive method use. Methods: We fielded a nationally representative survey in the U.S. in English and Spanish in 2022, surveying non-sterile 15-44-year-olds assigned female sex at birth. Among current and prospective contraceptive users (unweighted n = 2119), we describe preferred method use, reasons for non-use, and differences in preferred method use by sociodemographic characteristics. We conduct logistic regression analyses examining the association between four aspects of person-centered healthcare access and preferred contraceptive method use. Findings: A quarter (25.2%) of current and prospective users reported there was another method they would like to use, with oral contraception and vasectomy most selected. Reasons for non-use of preferred contraception included side effects (28.8%), sex-related reasons (25.1%), logistics/knowledge barriers (18.6%), safety concerns (18.3%), and cost (17.6%). In adjusted logistic regression analyses, respondents who felt they had enough information to choose appropriate contraception (Adjusted Odds Ratio [AOR] 3.31; 95% CI 2.10, 5.21), were very (AOR 9.24; 95% CI 4.29, 19.91) or somewhat confident (AOR 3.78; 95% CI 1.76, 8.12) they could obtain desired contraception, had received person-centered contraceptive counseling (AOR 1.72; 95% CI 1.33, 2.23), and had not experienced discrimination in family planning settings (AOR 1.58; 95% CI 1.13, 2.20) had increased odds of preferred contraceptive method use. Interpretation: An estimated 8.1 million individuals in the U.S. are not using a preferred contraceptive method. Interventions should focus on holistic, person-centered contraceptive access, given the implications of information, self-efficacy, and discriminatory care for preferred method use. Funding: Arnold Ventures.

"Have you ever wanted or needed an abortion you did not get?" Data from a 2022 nationally representative online survey in the United States.

OBJECTIVE: Describe the prevalence of considering, wanting, and not obtaining a wanted abortion among a nationally representative sample of 15-44 year olds in the United States who had ever been pregnant. STUDY DESIGN: We analyzed data from ever-pregnant respondents (unweighted n = 1789) from a larger online survey about contraceptive access using the nationally representative AmeriSpeak panel. Among those not obtaining wanted abortions, weighted frequencies for sociodemographic characteristics and reasons for not getting the abortion are presented. RESULTS: Nearly 6% of the full sample reported having wanted an abortion they did not obtain. In open-ended responses, respondents most frequently reported individual reasons (43.8%) for not getting an abortion (e.g., changing their mind; personal opposition) and financial, logistical, or informational barriers (24.7%) likely related to policy. A quarter (24.1%) of the sample reported a past abortion. Among those who reported no past abortions, about one-fifth had considered abortion in the past, and 6.8% had wanted or needed one. Among those reporting no prior abortions who had considered abortion, only a third (34.3%) also report ever wanting or needing one. CONCLUSIONS: This study begins to quantify the experience, even before the Supreme Court's 2022 decision in Dobbs v. Jackson Women's Health Organization, of being unable to obtain a wanted abortion. Additionally, findings suggest that people in a national sample will answer questions about whether and why they did not obtain a wanted abortion. IMPLICATIONS: This study provides the first known national estimates of lifetime history of not getting a wanted abortion. Survey questions can be used for future research. Prospective and ongoing measurement of the inability to get a wanted abortion could be one part of documenting the effects of Dobbs on abortion access.

Abortion Aftercare Instructions in the United States: A Content Analysis of Patient Handouts.

BACKGROUND: At the clinical visit for abortion care, patients typically receive a handout with information about what to expect and how to care for themselves after the abortion. Published guidelines give little to no guidance regarding the content of postabortion instructions. METHODS: We collected aftercare instruction handouts for first trimester procedural and medication abortion from abortion clinics throughout the United States. Instructions were coded and analyzed using conventional content analysis. RESULTS: Of the 84 unique aftercare handouts we received, most included information about symptoms to expect (included in 98% of procedural handouts, 97% of medication handouts), how to manage symptoms (included in 100% of procedural handouts, 100% of medication handouts), and specific behaviors to avoid (included in 94% of procedural handouts, 66% of medication handouts). The most common behavioral avoidance instructions were "pelvic rest" (included in 90% of procedural handouts, 63% of medication handouts), avoiding strenuous activity (included in 61% of procedural handouts, 29% of medication handouts), and avoiding submersion in water (included in 41% of procedural handouts, 26% of medication handouts). Handouts varied with regard to the extent and duration of specific recommendations. They also varied in tone, word choice, and other characteristics. CONCLUSIONS: There exists a wide range of abortion aftercare instructions throughout the United States. Inconsistency among instructions may reflect a lack of published, evidence-based clinical guidelines. Standardizing aftercare instruction handouts based on patient-oriented evidence could improve patient experience after abortion.

State abortion policies and Medicaid coverage of abortion are associated with pregnancy outcomes among individuals seeking abortion recruited using Google Ads: A national cohort study.

OBJECTIVE: A major challenge to understanding barriers to abortion is that those individuals most affected may never reach an abortion provider, making the full impact of restrictive policies difficult to measure. The Google Ads Abortion Access Study used a novel method to recruit individuals much earlier in the abortion-seeking process. We aimed to understand how state-level abortion policies and Medicaid coverage of abortion influence individuals' ability to obtain wanted abortions. METHODS: We employed a stratified sampling design to recruit a national cohort from all 50 states searching Google for abortion care. Participants completed online baseline and 4-week follow-up surveys. The primary independent variables were: 1) state policy environment and 2) state coverage of abortion for people with Medicaid. We developed multivariable multinomial mixed effects models to estimate the associations between each state-level independent variable and pregnancy outcome. RESULTS: Of the 874 participants with follow-up data, 48% had had an abortion, 32% were still seeking an abortion, and 20% were planning to continue their pregnancies at 4 weeks follow-up. Individuals in restricted access states had significantly higher odds of planning to continue the pregnancy at follow-up than participants in protected access states (aOR = 1.70, 95% CI = 1.08, 2.70). Individuals in states that do not provide coverage of abortion for people with Medicaid had significantly higher odds of still seeking an abortion at follow-up (aOR = 1.80, 95% CI = 1.24, 2.60). Individuals living in states without Medicaid coverage were significantly more likely to report that having to gather money to pay for travel expenses or for the abortion was a barrier to care. CONCLUSIONS: Restrictive state-level abortion policies are associated with not having an abortion at all and lack of coverage for abortion is associated with prolonged abortion seeking. Medicaid coverage of abortion appears critical to ensuring that all people who want abortions can obtain them.

Interprofessional Abortion Opposition: A National Survey and Qualitative Interviews with Abortion Training Program Directors at U.S. Teaching Hospitals.

CONTEXT: Hospital policies and culture affect abortion provision. The prevalence and nature of colleague opposition to abortion and how this opposition limits abortion care in U.S. teaching hospitals have not been investigated. METHODS: As part of a mixed-methods study, a nationwide survey of residency and site directors at 169 accredited obstetrics-gynecology training programs was conducted in 2015-2016, and 18 in-depth interviews with program directors were conducted in 2014 and 2017. The prevalence and nature of interprofessional opposition were examined using descriptive statistics, and regional differences were investigated using logistic regression. A modified grounded theoretical approach was used to analyze interview data. RESULTS: Among the 91% of survey respondents who reported that they or their colleagues had wanted or needed to provide abortions in the prior year, 69% faced opposition from colleagues. Most commonly, opposition came from nurses (58%), nursing administration (30%) and anesthesiologists (30%), manifesting as resistance to participating in or cooperating with procedures (51% and 38%, respectively). Fifty-nine percent of respondents had denied care to patients in the prior year because of colleagues' opposition. Respondents in the Midwest and South were more likely than those in the Northeast to deny abortion care to patients because of such opposition (odds ratios, 3.2 and 4.4, respectively). Interviews revealed how participants had to circumvent opposing colleagues, making abortion provision difficult and leading to delays in and, infrequently, denial of abortion care. CONCLUSIONS: Interprofessional opposition to abortion is widespread in U.S. teaching hospitals. Interventions are needed that prioritize patients' needs while recognizing the challenges hospital colleagues face in their abortion participation decisions.

Access to IUD removal: Data from a mystery-caller study.

OBJECTIVE: This study describes access and barriers to intrauterine device (IUD) removal appointments in 10 mid-sized cities in the United States. STUDY DESIGN: This mystery caller study utilized a sampling frame of health centers in 10 mid-sized cities gathered from 3 search engines. We gathered data about the timing of the next available appointment, the requirements for additional appointments prior to IUD removal, and the out-of-pocket cost. We used descriptive statistics to describe the availability and cost of IUD removal visits, and compared results between primary care clinics and family planning or gynecology clinics. Any additional information regarding why a visit was not available or other requirements for IUD removal that was provided to the researcher was also recorded. RESULTS: Of 229 clinics included for analysis, 60.7% could offer an IUD removal appointment to the mystery caller, and the majority of these could provide an initial appointment within 2 weeks (61.2%), with a median of 10 days. Of clinics offering IUD removal, 17.3% required more than one visit before removing the IUD, and 43.2% confirmed that IUD removal would occur at the first visit. Five clinics (5.6%) reported that they would not remove an IUD that was not placed at their clinic. Sliding scale fees were offered at 16.3% of clinics. For the clinics that cited an out-of-pocket cost and did not offer sliding scale fees, the median cost of the IUD removal was $262, with a range of $50 to over $1000. Neither appointment availability nor cost differed between primary care and family planning or gynecology clinics. CONCLUSIONS: Overall, timely IUD removal appointments were available at the clinics we sampled, but both financial and clinic policy barriers to IUD removal were documented, including the need for multiple appointments and the total out-of-pocket costs. IMPLICATIONS: In our current climate focused on improving access to IUDs, it is essential to address and reduce barriers to IUD removal when desired, in order to preserve reproductive autonomy.

The contraceptive needs and pregnancy desires of women after incarceration: A qualitative study.

OBJECTIVE: Prior qualitative research with women incarcerated at Rikers Island Jail asked women to anticipate their future contraceptive needs and pregnancy desires upon re-entering the community. We conduct this follow-up study to understand better the actual contraceptive needs and pregnancy desires experienced by women after incarceration. STUDY DESIGN: We conducted semi-structured in-depth interviews in New York City in 2014 with 10 women incarcerated within the past three years. We coded transcripts using an iterative process, identified emerging themes, and stopped recruitment after reaching thematic saturation. RESULTS: Most participants desired to wait to become pregnant until they had stable housing, income, and employment. A few faced systemic barriers to obtaining contraception, including the process of re-applying for insurance and obtaining medical appointments. For many, incarceration disrupted their use of contraception, insurance status, and relationship with trusted medical providers. Most women lacked trust in the new health professionals they encountered after incarceration. CONCLUSIONS: Incarceration disrupted medical care in general, and contraceptive care in particular. Assistance should be provided to re-apply for insurance, make appointments, and support women to see trusted health professionals. IMPLICATIONS: Incarceration further disenfranchises an already marginalized community through disrupting access to medical care and constrains women's reproductive autonomy long after return to the community.

Taking the provider "out of the loop:" patients' and physicians' perspectives about IUD self-removal.

OBJECTIVE: This study describes the perspectives of patients and providers about intrauterine device (IUD) self-removal. STUDY DESIGN: This qualitative study is a subanalysis of two datasets from a single project, which included semistructured individual interviews with 15 patients and 12 physicians. We derived the data for this analysis from portions of the interviews pertaining to IUD self-removal and provider removal. We analyzed data using deductive and inductive techniques to perform content and thematic analyses. RESULTS: The majority of patients and physicians cited both concerns about and potential benefits of IUD self-removal. Patients cited concerns about safety as the reason they did not wish to remove their own IUD, but physicians did not share these concerns; instead, physicians were apprehensive about not being involved in the discussion to remove the IUD. Both patients and physicians valued having the provider "in the loop" and reported fears about hasty or coerced removal. CONCLUSIONS: IUD self-removal is an option that some patients may be interested in. Addressing concerns about safety may make self-removal more appealing to some patients. Addressing physicians' concern about "hasty" removal may require additional training so that providers are better able to support patients' decision making around contraceptive use. IMPLICATIONS: The option of self-removal could have a positive impact on reproductive autonomy and patient decision making.

"I wish they could hold on a little longer": physicians' experiences with requests for early IUD removal.

OBJECTIVE: This study describes the perceptions and experiences of family physicians when women request early intrauterine device (IUD) removal. STUDY DESIGN: This qualitative study included semistructured individual interviews with 12 physicians who encountered patients seeking early IUD removal. We identified eligible participants via chart review. We analyzed interviews using deductive and inductive techniques to identify content and themes. RESULTS: Physicians consistently referred to IUDs as the "best" or their "favorite" method, and several joked that they tried to "sell" the IUD during contraceptive counseling. Most reported having mixed or negative feelings when patients opted to remove the IUD. Most encouraged their patients to continue the IUD, hoping to delay removal until symptoms resolved so that removal was not needed. Some physicians reported feeling guilty or as if they had "failed" when a patient wanted the IUD removed. Many providers reported a conflict between valuing patient autonomy and feeling that early removal was not in the patient's best interest. CONCLUSIONS: Physicians have complex and contradictory feelings about early IUD removal. While most providers acknowledged the need for patient autonomy, they still reported encouraging IUD continuation based on their own opinion about the IUD. IMPLICATIONS: While IUDs are highly effective and well-liked contraceptives, providers' responses to IUD removal requests have implications for both reproductive autonomy as well as the doctor-patient relationship. More work is needed to ensure that providers remove a patient's IUD when requested.

"She just told me to leave it": Women's experiences discussing early elective IUD removal.

OBJECTIVE: The objective of this study is to describe the thoughts and experiences of women who report discussing intrauterine device (IUD) removal within 9 months of insertion. STUDY DESIGN: This is a qualitative study, consisting of semistructured individual interviews with 16 women who considered early elective IUD removal. We identified eligible participants via chart review. We analyzed interviews using a modified grounded theory approach. RESULTS: While pain and bleeding were prominent reasons for removal, women also discussed many other symptoms and concerns. Most women reported a strong desire to have a successful IUD experience, and all reported waiting for symptoms to resolve prior to their visit. Some women reported that providers supported their choice, while others reported that providers preferred that they continue the IUD despite symptoms and concerns. Some women reported providers' resistance or refusal to remove the IUDs. The women who reported that their providers were neutral about IUD removal more frequently expressed satisfaction with the visit. When the provider resisted removal, women felt frustrated, even as they acknowledged their doctor's good intentions. In several cases, this may have hurt the doctor-patient relationship. CONCLUSIONS: When physicians resist early elective IUD removal, it may impact patient satisfaction and even jeopardize the doctor-patient relationship. IMPLICATIONS: Though IUDs are highly effective and well-liked contraceptives, some patients choose to discontinue the method. Because provision of patient-centered contraceptive care includes IUD removal when requested, providers must ensure that their counseling is unbiased and that they do not place perceived or real barriers to IUD removal.

Reproductive coercion: an under-recognized challenge for primary care patients.

BACKGROUND: Reproductive coercion impacts many women of reproductive age. OBJECTIVES: We sought to explore how reproductive coercion, including pregnancy coercion and birth control sabotage, impacts women in a primary care population. METHODS: We administered a survey to women accessing care at a family medicine clinic in the Bronx, NY. Reproductive coercion was defined as a positive response to at least one of five questions adapted from previous studies. We assessed the association of reproductive and demographic characteristics with a lifetime history of reproductive coercion. RESULTS: At least one form of reproductive coercion was reported by 24% of the 97 respondents. Current lack of personal safety and a history of transactional sex for money or a place to stay were significantly associated with having experienced reproductive coercion (all P ≤ 0.02). CONCLUSIONS: Reproductive coercion was common among women of reproductive age at this urban family medicine clinic in an underserved community, and was associated with other forms of control and violence. Clinicians are advised to discuss birth control sabotage and pregnancy coercion with their patients.

"I Don't Want to Go Anywhere Else": Patient Experiences of Abortion in Family Medicine.

BACKGROUND AND OBJECTIVES: Prior studies have demonstrated that most women are comfortable with the option of receiving early abortion care in the family medicine setting, and patients who received early abortion care in this context report satisfaction with their experience. There are few qualitative studies, however, that explore abortion experiences in the family medicine setting. This study aimed to better understand influential factors in women's choices and experiences of their family medicine setting for abortion care. METHODS: We conducted semi-structured interviews with 15 women who received early abortion care at an urban federally qualified health center offering full-spectrum family medicine. Transcripts were analyzed in NVivo, using editing and immersion/crystallization approaches. RESULTS: Women who received abortion care in this setting were highly satisfied. Though many were surprised when they learned abortion care was available, their responses were favorable, and their experiences were positive. Our results indicate that connection to the clinic setting and to the provider who performed the abortion created a context of trust and comfort. Further, women in our study appreciated the privacy offered by a general medical setting as well as the convenience and continuity of care afforded by accessing abortion care in their accustomed primary care setting. CONCLUSIONS: Women in our study reported high levels of satisfaction with care and would recommend this setting to others. In a context of increasing restrictions on abortion, family physicians are well-positioned to increase access by including abortion care in the range of reproductive health services offered in their primary care practice settings.

A Review of Contraception and Abortion Content in Family Medicine Textbooks.

BACKGROUND AND OBJECTIVES: Family physicians are critical providers of reproductive health care in the United States, and family physicians and trainees refer to textbooks as a source of clinical information. This study evaluates the coverage of reproductive health topics in current family medicine textbooks. METHODS: We identified 12 common family medicine textbooks through a computerized literature search and through the recommendations of a local family medicine clerkship and evaluated 24 areas of reproductive health content (comprising contraceptive care, management of early pregnancy loss, and provision of induced abortion) for accuracy and thoroughness using criteria that we created based on the latest guidelines. RESULTS: All contraceptive methods evaluated were addressed in more than half of the textbooks, though discrepancies existed by method, with intrauterine devices (IUDs), external (male) condoms, and diaphragms addressed most frequently (10/12 texts) and male and female sterilization addressed least frequently (8/12 texts). While most contraceptive methods, when addressed, were usually addressed accurately, IUDs were often addressed inaccurately. Coverage of early pregnancy loss management was limited to 7/12 texts, and coverage of early abortion methods was even more limited, with only 4/12 texts addressing the topic. CONCLUSIONS: Family medicine textbooks do not uniformly provide correct and thorough information on reproductive health topics relevant to family medicine, and attention is needed to ensure that family physicians are receiving appropriate information and training to meet the reproductive health needs of US women.

What Women Want: A Qualitative Study of Contraception in Jail.

OBJECTIVES: We undertook this study to understand women's perceptions of receiving contraception at Rikers Island Jail. METHODS: We conducted semi-structured in-depth interviews in 2011 to 2012 with 32 women incarcerated at Rikers Island Jail. We analyzed the data using standard qualitative techniques. RESULTS: Almost all participants believed that contraception should be provided at the jail. However, many said they would hesitate to use these services themselves. Reservations were caused in part by women's negative views of health care services at the jail. Fears about the safety of birth control, difficulties associated with follow-up in the community, and desire for pregnancy were other factors that influenced interest in accepting contraception. CONCLUSIONS: Contraception at the jail must be provided by trusted medical providers delivering high quality care with the goal of allowing women to control their own fertility; this would ensure that women could access birth control and cease using birth control when desired.

Developing patient-centered teams: The role of sharing stories about patients and patient care.

Research indicates that health care teams are good for staff, patients, and organizations. The characteristics that make teams effective include shared objectives, mutual respect, clarity of roles, communication, trust, and collaboration. We were interested in examining how teams develop these positive characteristics. This paper explores the role of sharing stories about patients in developing patient-centered teams. Data for this paper came from 1 primary care clinic as part of a larger Providers Share Workshop study conducted by the University of Michigan. Each workshop included 5 facilitated group sessions in which staff met to talk about their work. This paper analyzes qualitative data from the workshops. Through an iterative process, research team members identified major themes, developed a coding scheme, and coded transcripts for qualitative data analysis. One of the most powerful ways group members connected was through sharing stories about their patients. Sharing clinical cases and stories helped participants bond around their shared mission of patient-centered care, build supportive relationships, enhance compassion for patients, communicate and resolve conflict, better understand workflows and job roles, develop trust, and increase morale. These attributes highlighted by participants correspond to those documented in the literature as important elements of teambuilding and key indicators of team effectiveness. The sharing of stories about patients seems to be a promising tool for positive team development in a primary care clinical setting and should be investigated further.

The accuracy of using last menstrual period to determine gestational age for first trimester medication abortion: a systematic review.

OBJECTIVE: We sought to evaluate the accuracy of assessing gestational age (GA) prior to first trimester medication abortion using last menstrual period (LMP) compared to ultrasound (U/S). STUDY DESIGN: We searched Medline, Embase and Cochrane databases through October 2013 for peer-reviewed articles comparing LMP to U/S for GA dating in abortion care. Two teams of investigators independently evaluated data using standard abstraction forms. The US Preventive Services Task Force and Quality Assessment of Diagnostic Accuracy Studies guidelines were used to assess quality. RESULTS: Of 318 articles identified, 5 met inclusion criteria. Three studies reported that 2.5-11.8% of women were eligible for medication abortion by LMP and ineligible by U/S. The number of women who underestimated GA using LMP compared to U/S ranged from 1.8 to 14.8%, with lower rates found when the sample was limited to a GA <63 days. Most women (90.5-99.1%) knew their LMP, 70.8-90.5% with certainty. CONCLUSION: Our results support that LMP can be used to assess GA prior to medication abortion at GA <63 days. Further research looking at patient outcomes and identifying women eligible for medication abortion by LMP but ineligible by U/S is needed to confirm the safety and effectiveness of providing medication abortion using LMP alone to determine GA.