Measuring a Critical Component of Contraceptive Decision Making: The Contraceptive Concerns and Beliefs Scale.

INTRODUCTION: Concerns about safety and side effects from contraceptives are widespread and related to reluctance to use them. Measuring these concerns is an essential component of understanding contraceptive decision-making and guiding contraceptive and interpregnancy clinical care. METHODS: We used qualitative research and item response theory to develop and test a psychometric instrument to measure contraceptive concerns and beliefs. We developed 55 candidate scale items and tested them among 572 adolescents and adults across nine California healthcare facilities in 2019-2020. We derived a 6-item scale and assessed differences by age and social determinants of health with multivariable regression. RESULTS: In qualitative data, participants voiced both concerns and positive beliefs about contraception. Quantitative survey respondents were aged 21 years on average, and 24% were parous. Over half (54%) worried contraception has dangerous side effects, and 39% worried it is unnatural. The mean Contraceptive Concerns score, increasing with higher concerns, was 1.85 (SD: 1.00, range 0-4, α = 0.81). Items fit a partial credit item response model and met prespecified criteria for internal structure validity. Contraceptive use declined with increasing Concerns score (adjusted prevalence ratio [aPR] = 0.81 [0.72-0.92]). Scores were elevated among Black (mean: 2.06; aß = 0.34 [0.09, 0.59]) and Multiracial or other race (2.11; aß = 0.34 [0.02, 0.66]) respondents vs. White (1.66), but not Latinx respondents (1.81; aß = 0.11 [- 0.11, 0.33]). Scores were also elevated among participants with lower maternal education (high school/Associate's 1.89 versus college 1.60; aß = 0.28 [0.04, 0.53]). DISCUSSION: The psychometrically robust Concerns instrument can be used in research to measure autonomous contraceptive decision-making and to design person-centered care.

Predictive ability of the Desire to Avoid Pregnancy scale.

BACKGROUND: A longstanding gap in the reproductive health field has been the availability of a screening instrument that can reliably predict a person's likelihood of becoming pregnant. The Desire to Avoid Pregnancy Scale is a new measure; understanding its sensitivity and specificity as a screening tool for pregnancy as well as its predictive ability and how this varies by socio-demographic factors is important to inform its implementation. METHODS: This analysis was conducted on a cohort of 994 non-pregnant participants recruited in October 2018 and followed up for one year. The cohort was recruited using social media as well as advertisements in a university, school, abortion clinic and outreach sexual health service. Almost 90% of eligible participants completed follow-up at 12 months; those lost to follow-up were not significantly different on key socio-demographic factors. We used baseline DAP score and a binary variable of whether participants experienced pregnancy during the study to assess the sensitivity, specificity, area under the ROC curve (AUROC) and positive and negative predictive values (PPV and NPV) of the DAP at a range of cut-points. We also examined how the predictive ability of the DAP varied according to socio-demographic factors and by the time frame considered (e.g., pregnancy within 3, 6, 9 and 12 months). RESULTS: At a cut-point of 2 on the 0-4 range of the DAP scale, the DAP had a sensitivity of 0.78, a specificity of 0.81 and an excellent AUROC of 0.87. In this sample the cumulative incidence of pregnancy was 16% (95%CI 13%, 18%) making the PPV 43% and the NPV 95% at this cut-point. The DAP score was the factor most strongly associated with pregnancy, even after age and number of children were taken into account. The association between baseline DAP score and pregnancy did not differ across time frames. CONCLUSIONS: This is the first study to assess the DAP scale as a screening tool and shows that its predictive ability is superior to the limited pre-existing pregnancy prediction tools. Based on our findings, the DAP could be used with a cut-point selected according to the purpose.

"She should support me, she's my doctor:" Patient perceptions of agency in contraceptive decision-making in the clinical encounter in Northern California.

INTRODUCTION: Agency in contraceptive decision-making is an essential aspect of reproductive autonomy. We conducted qualitative research to investigate what agency means to patients seeking contraceptive care to inform the development of a validated measure of this construct. METHODOLOGY: We held four focus group discussions and seven interviews with sexually-active individuals assigned female at birth, ages 16-29 years, recruited from reproductive health clinics in Northern California. We explored experiences in contraceptive decision-making during the clinic visit. We coded data in ATLAS.ti and by hand, compared codes across three coders, and used thematic analysis to identify salient themes. RESULTS: The sample mean age was 21 years, with 17% of participants identifying as Asian, 23% as Black, 27% as Latinx, 17% as Multiracial/other, and 27% as white. Overall, participants reported active and engaged decision-making in their recent contraceptive visit but noted experiences that had undermined their agency in the past. They described how non-judgmental care allowed them to communicate openly, affirming their ability to make their own decisions. However, several mentioned how unexpected contraceptive side effects after the visit had reduced their sense of agency over their decision in retrospect. Several participants, including those who identified as Black, Latinx, and/or Asian, described prior experiences where pressure to use a contraceptive method had undermined their agency and where they had switched providers to regain agency over their contraceptive decisions. DISCUSSION: Most participants were aware of their agency during contraceptive visits and how it varied in different experiences with providers and the healthcare system. Patient perspectives can help to inform measurement development and ultimately the delivery of care that supports contraceptive agency.

Transforming masculine norms to improve men's contraceptive acceptance: results from a pilot intervention with men in western Kenya.

Men's adherence to constraining male gender norms can lead them to resist contraceptive use. Very few interventions have attempted to transform masculine norms to encourage greater contraceptive acceptance and gender equality. We designed and evaluated a small-scale community-based intervention targeting the masculine norms tied to contraceptive resistance among partnered men (N = 150) in two western Kenya communities (intervention vs. control). Pre-post survey data fit to linear and logistic regression models evaluated differences in post-intervention outcomes, accounting for pre-intervention differences. Intervention participation was associated with increases in contraceptive acceptance scores (adjusted coefficient (aß) 1.04; 95% confidence interval (CI) 0.16, 1.91; p = 0.02) and contraceptive knowledge scores (aß 0.22; 95% CI 0.13, 0.31; p < 0.001) and with contraceptive discussions with one's partner (adjusted Odds Ratio (aOR) 3.96; 95% CI 1.21, 12.94; p = 0.02) and with others (aOR 6.13; 95% CI 2.39, 15.73; p < 0.001). The intervention was not associated with contraceptive behavioural intention or use. Our findings demonstrate the promise of a masculinity-driven intervention on increasing men's contraceptive acceptance and positive contraceptive involvement. A larger randomised trial is needed to test the effectiveness of the intervention among men as well as among couples.

Agency in Contraceptive Decision-Making in Patient Care: a Psychometric Measure.

BACKGROUND: Patient agency in contraceptive decision-making is an essential component of reproductive autonomy. OBJECTIVE: We aimed to develop a psychometrically robust measure of patient contraceptive agency in the clinic visit, as a measure does not yet exist. DESIGN: For scale development, we generated and field tested 54 questionnaire items, grounded in qualitative research. We used item response theory-based methods to select and evaluate scale items for psychometric performance. We iteratively examined model fit, dimensionality, internal consistency, internal structure validity, and differential item functioning to arrive at a final scale. PARTICIPANTS: A racially/ethnically diverse sample of 338 individuals, aged 15-34 years, receiving contraceptive care across nine California clinics in 2019-2020. MAIN MEASURES: Contraceptive Agency Scale (CAS) of patient agency in preventive care. KEY RESULTS: Participants were 20.5 mean years, with 36% identifying as Latinx, 26% White, 20% Black, 10% Asian/Native Hawaiian/Pacific Islander. Scale items covered the domains of freedom from coercion, non-judgmental care, and active decision-making, and loaded on to a single factor, with a Cronbach's α of 0.80. Item responses fit a unidimensional partial credit item response model (weighted mean square statistic within 0.75-1.33 for each item), met criteria for internal structure validity, and showed no meaningful differential item functioning. Most participants expressed high agency in their contraceptive visit (mean score 9.6 out of 14). One-fifth, however, experienced low agency or coercion, with the provider wanting them to use a specific method or to make decisions for them. Agency scores were lowest among Asian/Native Hawaiian/Pacific Islander participants (adjusted coefficient: -1.5 [-2.9, -0.1] vs. White) and among those whose mothers had less than a high school education (adjusted coefficient; -2.1 [-3.3, -0.8] vs. college degree or more). CONCLUSIONS: The Contraceptive Agency Scale can be used in research and clinical care to reinforce non-coercive service provision as a standard of care.

Ranges of pregnancy preferences and contraceptive use: Results from a population-based survey in the southeast United States.

CONTEXT: Understanding how pregnancy preferences shape contraceptive use is essential for guiding contraceptive interventions and policies that center individuals' preferences and desires. Lack of rigorous measurement of pregnancy preferences, particularly on the population level, has been a methodologic challenge. METHODS: We investigated associations between prospective pregnancy preferences, measured with a valid instrument, the Desire to Avoid Pregnancy (DAP) scale, and contraceptive use in a representative sample of 2601 pregnancy-capable self-identified women, aged 18-44 years, in Alabama and South Carolina (2017-2018). We used multivariable regression with weighting to investigate how probability of modern contraceptive use, and use of different contraceptive method types, changed with increasing preference to avoid pregnancy. RESULTS: Desire to Avoid Pregnancy scale scores (range:0-4, 4 = greater preference to avoid pregnancy, median = 2.29, IQR: 1.57-3.14; α:0.95) were strongly associated with contraceptive use among sexually active respondents (aPR = 1.15 [1.10, 1.20]; predicted 45% using contraception among DAP = 0, 62% among DAP = 2, 86% among DAP = 4). Method types used did not differ by DAP score. The most common reasons for nonuse were concern over side effects and not wanting to use a method (32% each) among respondents with mid-range and high DAP scores. Among those with mid-range DAP scores, 20% reported nonuse due to not minding if pregnancy were to occur (vs. 0% among those with high DAP scores). CONCLUSIONS: Pregnancy preferences strongly influence likelihood of contraceptive use. Providion of appropriate contraceptive care to those not explicitly desiring pregnancy must differentiate between ranges of feelings about pregnancy, perceived drawbacks to contraceptive use, and legitimate psychological and interpersonal benefits of nonuse to promote autonomy in contraceptive decision-making.

Comparison of Pregnancy Preferences Preceding vs Year 1 of the COVID-19 Pandemic.

Importance: Understanding how the COVID-19 pandemic affected people's desire to avoid pregnancy is essential for interpreting the pandemic's associations with access to reproductive health care and reproductive autonomy. Early research is largely cross-sectional and relies on people's own evaluations of how their desires changed. Objective: To investigate longitudinal changes in pregnancy desires during the year before and the first year of the COVID-19 pandemic. Design, Setting, and Participants: In this cohort study, participants reported their pregnancy preferences at baseline and quarterly for up to 18 months between March 2019 and March 2021. An interrupted time series analysis with mixed-effects segmented linear regression was used to examine population-averaged time trends. People were recruited from 7 primary and reproductive health care facilities in Arizona, New Mexico, and Texas. Participants were sexually active, pregnancy-capable people aged 15 to 34 years who were not pregnant or sterilized. Data analysis was performed from September 2021 to January 2022. Exposures: Continuous time, with knots at the onset of the first (July 1, 2020, summer surge) and second (November 1, 2020, fall surge) COVID-19 cases surges in the Southwest. Main Outcomes and Measures: Preferences around potential pregnancy in the next 3 months, measured using the validated Desire to Avoid Pregnancy (DAP) scale (range, 0-4, with 4 indicating a higher desire to avoid pregnancy). Results: The 627 participants in the analytical sample had a mean (SD) age of 24.9 (4.9) years; 320 (51.0%) identified as Latinx and 180 (28.7%) as White. Over the year before the first case surge in the US Southwest in summer 2020, population-averaged DAP scores decreased steadily over time (-0.06 point per quarter; 95% CI, -0.07 to -0.04 point per quarter; P < .001). During the summer 2020 surge, DAP scores stopped declining (0.05 point per quarter; 95% CI, -0.03 to 0.13 point per quarter; change in slope, P < .001). During the fall 2020 surge, however, DAP scores declined again at -0.11 point per quarter (95% CI, -0.26 to 0.04 point per quarter; change in slope, P = .10). Participants aged 15 to 24 years and those who were nulliparous and primiparous experienced greater declines in DAP score before the summer surge, and greater reversals of decline between summer and fall 2020, than did those who were aged 25 to 34 years and multiparous. Conclusions and Relevance: These findings suggest that the COVID-19 pandemic onset was associated with the stalling of a prior trend toward greater desire for pregnancy over time, particularly for people earlier in their reproductive lives.

Predictors of prior unsuccessful pharmacy abortion attempts among women presenting for abortion in government certified clinics in Nepal.

OBJECTIVE: Although abortion in Nepal is broadly legal and free of charge, many women seek abortion care outside the legal system, including from pharmacies. We evaluated the prevalence of, and factors associated with, prior unsuccessful abortion attempts among women presenting to 14 randomly-selected government approved abortion health facilities across Nepal. METHODS: Eligible participants were recruited in 2019 by trained research staff from certified abortion facilities. Participants (n = 1160) completed research staff-administered baseline surveys. We used multivariable mixed-effects logistic regression models to evaluate factors associated with having attempted pharmacy abortion prior to coming to the health facility. RESULTS: Almost one in seven (14%) women had tried to end their pregnancy before presenting to a participating clinic, often (9%) using medication obtained from a pharmacy. Women who lived farther from the clinic (aOR 1.28 per log hours travel time, 95% CI 1.10-1.49) and who reported financial difficulty in accessing the clinic (19% vs. 10%, aOR 2.10, 95% CI 1.20-3.70) had increased odds of having tried to access abortion through a pharmacy. CONCLUSION: Integrating pharmacies into the legal network of abortion providers may improve access to safe care, particularly for rural women with financial and practical travel limitations.

Home pregnancy test use and timing of pregnancy confirmation among people seeking health care.

OBJECTIVES: Understanding the timing of pregnancy suspicion and confirmation, including the role of home pregnancy tests, can facilitate earlier entry into pregnancy-related care and identify individuals likely to be impacted by gestation-based abortion restrictions. STUDY DESIGN: We use data from 259 pregnant individuals participating in a cross-sectional survey at 8 primary and reproductive health care clinics in 6 U.S. states (2016-2017). We use regression models to identify differences in utilization of HPTs, barriers to use, and to compare gestational duration at pregnancy confirmation. RESULTS: Three-quarters (74%) of respondents took a home pregnancy test as the first step in confirming pregnancy; this figure was lower among adolescents versus young adults (65 vs 81%, p = 0.01). Two-thirds (64%) reported delays in home testing, higher among adolescents (85%). People taking a test at home confirmed pregnancy 10 days earlier than those first testing at a clinic (41.3 vs 51.8 days gestation, p = 0.02). Those that did not test at home cited concerns about test accuracy (42%) and difficulties accessing one (26%). While overall 21% confirmed pregnancy at ≥7 weeks gestation, and 35% at ≥6 weeks, confirmation at ≥7 weeks was higher among adolescents versus young adults (47 vs 13%, p = 0.001), Latina versus white women (28 vs 11%, p = 0.02), food insecure versus secure women (28 vs 17%, p = 0.06), and people with unplanned versus planned/mistimed pregnancies (25 vs 13%, p = 0.07). CONCLUSIONS: Home pregnancy testing is common and associated with earlier pregnancy confirmation. Still, barriers to at-home testing are evident, particularly among adolescents. Efforts to expand access to home pregnancy tests and increase knowledge about their accuracy may be impactful in increasing utilization. IMPLICATIONS: While at home pregnancy testing is common and facilitates earlier confirmation of pregnancy, one in 5 confirm pregnancy at 7 weeks gestation or later (and one in 3 do so at 6 weeks or later). Gestational bans in the first trimester will disproportionately prevent young people, people of color, and those living with food insecurity from being able to access abortion.

Measuring Men's Gender Norm Beliefs Related to Contraception: Development of the Masculine Norms and Family Planning Acceptance Scale.

Male partner resistance is identified as a key factor that influences women's contraceptive use. Examination of the masculine norms that shape men's resistance to contraception-and how to intervene on these norms-is needed. To assess a gender-transformative intervention in Kenya, we developed and evaluated a masculinity-informed instrument to measure men's contraceptive acceptance-the Masculine Norms and Family Planning Acceptance (MNFPA) scale. We developed draft scale items based on qualitative research and administered them to partnered Kenyan men (n = 150). Item response theory-based methods were used to reduce and psychometrically evaluate final scale items. The MNFPA scale had a Cronbach's α of 0.68 and loaded onto a single factor. MNFPA scores were associated with self-efficacy and intention to accept a female partner's use of contraception; scores were not associated with current contraceptive use. The MNFPA scale is the first rigorously developed and psychometrically evaluated tool to assess men's contraceptive acceptance as a function of male gender norms. Future work is needed to test the MNFPA measure in larger samples and across different contexts. The scale can be used to evaluate interventions that seek to shift gender norms to increase men's positive engagement in pregnancy spacing and prevention.

Desire to avoid pregnancy and contraceptive use among female methadone patients in Los Angeles.

OBJECTIVE: Opioid use disorder (OUD) is increasing among U.S. women. Research indicates higher levels of unintended pregnancy among women with OUD as compared to the general population. Following formative in-depth research documenting the complexity of considerations around pregnancy in this population, we collected information on pregnancy preferences and contraceptive use among women attending methadone treatment. STUDY DESIGN: We surveyed women attending methadone clinics in Los Angeles in 2018. We used the Desire to Avoid Pregnancy (DAP) Scale, a 14-item instrument (0-4; 4 = highest desire to avoid pregnancy) to capture pregnancy preferences across 3 domains: cognitive desires, affective feelings, and anticipated consequences. We conducted factor analysis, descriptive analyses, and linear and logistic regressions to assess the DAP scale and to examine relationships between pregnancy preferences, sociodemographic characteristics, and contraceptive use. RESULTS: Women (n = 46) expressed the full range of pregnancy preferences (DAP score range: 0.4-4.0; mean: 2.24, standard deviation: 1.02; Cronbach's α = 0.92). Overall, 40% used contraception at last sex. Women who reported a greater preference to avoid pregnancy were marginally more likely to use contraception at last sex as compared to women who were more open to pregnancy (odds ratio = 1.73; p = 0.09). CONCLUSIONS: Similar to findings from other populations, responses to the Desire to Avoid Pregnancy scale among a sample of women with OUD revealed a broad range of pregnancy preferences. Pregnancy preferences were marginally associated with contraceptive use in this sample suggesting that the DAP may provide useful insights on pregnancy preferences that may facilitate contraceptive and preconception counseling in this population. IMPLICATIONS: Given the complexity of considerations around pregnancy for women with opioid use disorder, the DAP scale may be a valuable tool to identify women's pregnancy and childbearing preferences and to facilitate alignment of women's sexual and reproductive health desires with appropriate services.

Delayed Visits for Contraception Due to Concerns Regarding Pelvic Examination Among Women with History of Intimate Partner Violence.

BACKGROUND: Concern regarding pelvic examinations may be more common among women experiencing intimate partner violence. OBJECTIVE: We examined women's attitudes towards pelvic examination with history of intimate partner violence (pressured to have sex, or verbal, or physical abuse). DESIGN: Secondary analysis of data from a cluster randomized trial on contraceptive access. PARTICIPANTS: Women aged 18-25 were recruited at 40 reproductive health centers across the USA (2011-2013). MAIN MEASURES: Delays in clinic visits for contraception and preference to avoid pelvic examinations, by history of ever experiencing pressured sex, verbal, or physical abuse from a sexual partner, reported by frequency (never, rarely, sometimes, often). We used multivariable logistic regression with generalized estimating equations for clustered data. KEY RESULTS: A total of 1490 women were included. Ever experiencing pressured sex was reported by 32.4% of participants, with 16.5% reporting it rarely, 12.1% reporting it sometimes, and 3.8% reporting it often. Ever experiencing verbal abuse was reported by 19.4% and physical abuse by 10.2% of participants. Overall, 13.2% of participants reported ever having delayed going to the clinic for contraception to avoid having a pelvic examination, and 38.2% reported a preference to avoid pelvic examinations. In multivariable analysis, women reporting that they experienced pressured sex often had significantly higher odds of delaying a clinic visit for birth control (aOR 3.10 95% CI 1.39-6.84) and for reporting a preference to avoid pelvic examinations (aOR 2.91 95% CI 1.57-5.40). We found no associations between delay of clinic visits or preferences to avoid a pelvic examination and verbal or physical abuse. CONCLUSIONS: History of pressured sex from an intimate partner is common. Among women who have experienced pressured sex, concern regarding pelvic examinations is a potential barrier to contraception. Communicating that routine pelvic examinations are no longer recommended by professional societies could potentially reduce barriers and increase preventive healthcare visits.

Certainty and intention in pregnancy decision-making: An exploratory study.

OBJECTIVE: Abortion is often characterized as an inherently difficult decision, despite research demonstrating high decision certainty among abortion patients. Minimal research has examined decision certainty among people planning to continue a pregnancy. We examined whether women seeking abortion experience lower decision certainty than those planning to continue pregnancies and whether certainty differs by pregnancy intendedness. STUDY DESIGN: We administered the decisional conflict scale (DCS) to pregnant women (n = 149) at 8 U.S. primary and reproductive health clinics. Using Poisson regression models adjusted for sociodemographic and pregnancy characteristics, we evaluated differences in DCS scores (<25/100 vs ≥25/100) by pregnancy decision and whether pregnancy intention modified the effect of pregnancy decision on certainty. RESULTS: Over one-half (58%) of respondents planned to have an abortion, 32% to continue the pregnancy, and 10% were unsure. DCS scores were low overall (median 9.4/100; IQR: 1.6, 25.0), indicative of high certainty, and the percentage scoring ≥25/100, reflecting any uncertainty, did not differ by pregnancy decision (23% abortion vs 19% continuing, p = 0.55). In a multivariable model, there was no statistically significant interaction between pregnancy decision (abortion vs continuing pregnancy) and intention. However, the predicted percentage reporting any uncertainty among respondents with intended pregnancies was comparable among those decided on abortion (13%) and continuing the pregnancy (16%). Among those with unintended pregnancies, these figures were 25% among those decided on abortion vs 36% among those continuing. CONCLUSION: Levels of certainty about a pregnancy decision were high and appeared to depend more on whether the pregnancy was intended or unintended than on the pregnancy decision itself. IMPLICATIONS: Similar levels of uncertainty among individuals who decided to have an abortion versus continue a pregnancy challenge the narrative that abortion is a particularly difficult medical and personal decision. The prevalence of some uncertainty among respondents continuing pregnancies suggests voluntary options counseling may be useful for some patients in prenatal care settings.

Intrauterine Devices and Sexually Transmitted Infection among Older Adolescents and Young Adults in a Cluster Randomized Trial.

STUDY OBJECTIVE: Provider misconceptions regarding intrauterine device (IUD) safety for adolescents and young women can unnecessarily limit contraceptive options offered; we sought to evaluate rates of Neisseria gonorrhoeae or Chlamydia trachomatis (GC/CT) diagnoses among young women who adopted IUDs. DESIGN: Secondary analysis of a cluster-randomized provider educational trial. SETTING: Forty US-based reproductive health centers. PARTICIPANTS: We followed 1350 participants for 12 months aged 18-25 years who sought contraceptive care. INTERVENTIONS: The parent study assessed the effect of provider training on evidence-based contraceptive counseling. MAIN OUTCOME MEASURES: We assessed incidence of GC/CT diagnoses according to IUD use and sexually transmitted infection risk factors using Cox regression modeling and generalized estimating equations. RESULTS: Two hundred four participants had GC/CT history at baseline; 103 received a new GC/CT diagnosis over the 12-month follow-up period. IUDs were initiated by 194 participants. Incidence of GC/CT diagnosis was 10.0 per 100 person-years during IUD use vs 8.0 otherwise. In adjusted models, IUD use (adjusted hazard ratio [aHR], 1.31; 95% confidence interval [CI], 0.71-2.40), adolescent age (aHR, 1.28; 95% CI, 0.72-2.27), history of GC/CT (aHR, 1.23; 95% CI, 0.75-2.00), and intervention status (aHR, 1.12; 95% CI, 0.74-1.71) were not associated with GC/CT diagnosis; however, new GC/CT diagnosis rates were significantly higher among individuals who reported multiple partners at baseline (aHR, 2.0; 95% CI, 1.34-2.98). CONCLUSION: In this young study population with GC/CT history, this use of IUDs was safe and did not lead to increased GC/CT diagnoses. However, results highlighted the importance of dual sexually transmitted infection and pregnancy protection for participants with multiple partners.

Emotions over five years after denial of abortion in the United States: Contextualizing the effects of abortion denial on women's health and lives.

BACKGROUND: The Turnaway Study was the first to follow women denied abortions because of state law or facility policy over five years. The study has found negative effects on women's socioeconomic status, physical health, and on their children's wellbeing. However, women did not suffer lasting mental health consequences, prompting questions about the effects of denial on women's emotions. METHODS: In this mixed methods study, we used quantitative and qualitative interview data from the Turnaway Study to offer insight into these findings. We surveyed 161 women who were denied abortions at 30 facilities across the United States between 2008 and 2010 one week after the abortion denial and semiannually over five years. Mixed-effects regression analyses examined emotions about having been denied the abortion over time. To contextualize the quantitative findings, we draw on in-depth qualitative interviews with 15 participants, conducted in 2014-2015, for their accounts of their emotions and feelings over time. RESULTS: Survey participants reported both negative and positive emotions about the abortion denial one week after. Emotions became significantly less negative and more positive over their pregnancy and after childbirth. In multivariable models, lower social support, more difficulty deciding to seek abortion, and placing the baby for adoption were associated with reporting more negative emotions. Interviews revealed how, for some, belief in antiabortion narratives contributed to initial positive emotions. Subsequent positive life events and bonding with the child also led to positive retrospective evaluations of the denial. CONCLUSIONS: Findings of emergent positive emotions about having been denied an abortion suggest that individuals are able to cope emotionally with an abortion denial, although evidence that policies leading to abortion denial cause significant health and socioeconomic harms remains.

Implementation science: Scaling a training intervention to include IUDs and implants in contraceptive services in primary care.

Building capacity for contraceptive services in primary care settings, including for intrauterine devices (IUDs) and implants, can help to broaden contraceptive access across the US. Following a randomized trial in family planning clinics, we brought a provider training intervention to other clinical settings including primary care in all regions. This implementation science study evaluates a national scale-up of a contraceptive training intervention to varied practice settings from 2013 to 2019 among 3216 clinic staff serving an estimated 1.6 million annual contraceptive patients. We measured providers' knowledge and clinical practice changes regarding IUDs and implants using survey data. We estimated the overall intervention effect, and its relative effectiveness in primary care settings, with generalized estimating equations for clustered data. Patient-centered counseling improved, along with comfort with method provision and removal. Provider knowledge increased (p < 0.001), as did evidence-based counseling for IUDs (aOR 3.3 95% CI 2.8-3.9) and implants (aOR 3.5, 95% CI 3.0-4.1), and clinician competency in copper and levonorgestrel IUDs (aORs 1.8-2.6 95% CIs 1.5-3.2) and implants (aOR 2.4 95% CI 2.0-2.9). While proficiency was lower initially in primary care, gains were significant and at times greater than in Planned Parenthood health clinics. This intervention was effectively scaled, including in primary care settings with limited prior experience with these methods. Recent changes to Title X family planning funding rules exclude several large family planning providers, shifting greater responsibility to primary care and other settings. Scaling effective contraceptive interventions is one way to ensure capacity to offer patients full contraceptive services.

Abortion Policies in U.S. Teaching Hospitals: Formal and Informal Parameters Beyond the Law.

OBJECTIVE: To evaluate the prevalence and features of policies regulating abortion in U.S. teaching hospitals. METHODS: In this mixed-methods study, we conducted a national survey of obstetrics and gynecology teaching hospitals (2015-2016) and qualitative interviews (2014 and 2017) with directors at obstetrics and gynecology residency programs. We asked participants about hospital regulations on abortion and their perceptions of the nature and enforcement of these policies. Interview analysis was conducted with a grounded theoretical approach and informed development of the survey. The prevalence of policies was described using survey data; differences in policy structures by region were analyzed using a series of logistic regression models. RESULTS: Directors from 169 of 231 eligible training programs responded to the survey (73%). Institutional policies limited abortion beyond state law in 57% of teaching hospitals, most commonly in the Midwest and South (odds ratio [OR] 4.3, P<.01 for Midwest; OR 4.0, P=.001 for South vs Northeast). Policies varied in form (written and unwritten) and restricted abortion based on the indication for the procedure and gestational age. Nonmedically indicated, or "elective" procedures were more commonly restricted (48% of sites reporting any policy and 25% prohibiting these abortions altogether) than medically indicated ones (28% of sites reporting any policy.) Policies were created by those with institutional power, including hospital leadership and obstetrics and gynecology department chairs, and were perceived to be motivated by personal beliefs and a desire to avoid controversy. Rules were commonly enforced by medical specialists, hospital ethics committees, and department chairs. Qualitative data highlighted the convoluted nuances of these policies, which often put clinicians at odds with their professional mandates. DISCUSSION: Reportedly driven by broader institutional interests, obstetrics and gynecology teaching hospital policies often restricted abortion beyond state law to the detriment of abortion access and training opportunities. Vague or unwritten abortion policies, although difficult to navigate, gave health care providers some agency and flexibility over their practices.

Comparing Prospective and Retrospective Reports of Pregnancy Intention in a Longitudinal Cohort of U.S. Women.

CONTEXT: Measurement of pregnancy intentions typically relies on retrospective reporting, an approach that may misrepresent the extent of unintended pregnancy. However, the degree of possible misreporting is unclear, as little research has compared prospective and retrospective reports of intention for the same pregnancies. METHODS: Longitudinal data collected between 2010 and 2015 on 174 pregnancies were used to analyze the magnitude and direction of changes in intendedness (intended, ambivalent or unintended) between prospective and retrospective measurements of intendedness using versions of the London Measure of Unplanned Pregnancy (LMUP). Changes were assessed both continuously and categorically. Differences in the degree of change-by pregnancy outcome and participant characteristics-were examined using mixed-effects linear and logistic regression models. RESULTS: Over two and one-half years of follow-up, 143 participants reported 174 pregnancies. Approximately half showed changes in intention between the prospective and retrospective assessments, with 38% of participants reporting increased intendedness and 10% decreased intendedness. Reported intendedness increased more among those who gave birth (mean change in continuous LMUP score, 2.2) than among those who obtained an abortion (0.7), as well as among individuals with a college degree (4.1) than among those with a high school diploma (1.2). Participants who reported recent depression or anxiety symptoms showed more stable intentions (0.02) than those who did not (2.1). CONCLUSIONS: Retrospective measurement of pregnancy intentions may underestimate the frequency of unintended pregnancy, with such underestimation being greater among certain subgroups. Estimates based on retrospective reports thus may produce inaccurate impressions of intentionality. Further efforts to refine the measurement of pregnancy preferences are needed.