Trends In Primary Cesarean Section Rates Among Women With And Without Perinatal Mood And Anxiety Disorders.

Reducing the rate of cesarean sections among women considered at low risk for delivery by that method is a goal of Healthy People 2030. Prior research suggests that perinatal mood and anxiety disorders increase the risk for cesarean section, but data are limited. This cross-sectional study of commercially insured women examined the relationship between perinatal depression and anxiety disorders and primary (first-time) cesarean section rates, using administrative claims data for US in-hospital deliveries from the period 2008-17. Of the 360,225 delivery hospitalizations among 317,802 unique women, 24.0 percent included a delivery by primary cesarean section, and 3.1 percent carried a diagnosis of depression, anxiety, or both made during the index pregnancy. Using an adjusted generalized estimating equation, we found that the predicted probability of primary cesarean section was 3.5 percentage points higher, on average, among women with these disorders compared with those without them. Our findings confirm the importance of pursuing research to identify mechanisms by which perinatal depression and anxiety disorders increase the risk for primary caesarean section among women otherwise considered at low risk for delivery by that method, as well as effective interventions.

Trends in Suicidality 1 Year Before and After Birth Among Commercially Insured Childbearing Individuals in the United States, 2006-2017.

Importance: Suicide deaths are a leading cause of maternal mortality in the US, yet the prevalence and trends in suicidality (suicidal ideation and/or intentional self-harm) among childbearing individuals remain poorly described. Objective: To characterize trends in suicidality among childbearing individuals. Design, Setting, and Participants: This serial cross-sectional study analyzed data from a medical claims database for a large commercially insured population in the US from January 2006 to December 2017. There were 2714 diagnoses of suicidality 1 year before or after 698 239 deliveries among 595 237 individuals aged 15 to 44 years who were continuously enrolled in a single commercial health insurance plan. Data were analyzed from October 2019 to September 2020. Main Outcomes and Measures: The primary outcome was diagnosis of suicidality in childbearing individuals 1 year before or after birth based on the identification of relevant International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) and ICD-10-CM diagnosis codes during at least 1 inpatient or 2 outpatient visits. Results: Of 595 237 included childbearing individuals, the mean (SD) age at delivery was 31.9 (6.4) years. A total of 40 568 individuals (6.8%) were Asian, 52 613 (8.6%) were Black, 73 172 (12.1%) were Hispanic, 369 501 (63.1%) were White, and 59 383 (9.5%) had unknown or missing race/ethnicity data. A total of 2683 individuals were diagnosed with suicidality 1 year before or after giving birth for a total of 2714 diagnoses. The prevalence of suicidal ideation increased from 0.1% per 100 individuals in 2006 to 0.5% per 100 individuals in 2017 (difference, 0.4%; SE, 0.03; P < .001). Intentional self-harm prevalence increased from 0.1% per 100 individuals in 2006 to 0.2% per 100 individuals in 2017 (difference, 0.1%; SE, 0.02; P < .001). Suicidality prevalence increased from 0.2% per 100 individuals in 2006 to 0.6% per 100 individuals in 2017 (difference, 0.4%; SE, 0.04; P < .001). Diagnoses of suicidality with comorbid depression or anxiety increased from 1.2% per 100 individuals in 2006 to 2.6% per 100 individuals in 2017 (difference, 1.4%; SE, 0.2; P < .001). Diagnoses of suicidality with comorbid bipolar or psychotic disorders increased from 6.9% per 100 individuals in 2006 to 16.9% per 100 individuals in 2017 (difference, 10.1%; SE, 0.2; P < .001). Non-Hispanic Black individuals, individuals with lower income, and younger individuals experienced larger increases in suicidality over the study period. Conclusions and Relevance: In this cross-sectional study of US childbearing individuals, the prevalence of suicidal ideation and intentional self-harm occurring in the year preceding or following birth increased substantially over a 12-year period. Policy makers, health plans, and clinicians should ensure access to universal suicidality screening and appropriate treatment for pregnant and postpartum individuals and seek health system and policy avenues to mitigate this growing public health crisis, particularly for high-risk groups.

Michigan Emergency Department Leader Attitudes Toward and Experiences With Clinical Pathways to Guide Admission Decisions: A Mixed-methods Study.

OBJECTIVES: The objective was to characterize emergency department (ED) leader's attitudes toward potentially avoidable admissions and experiences with the use of clinical pathways to guide admission decisions, including the challenges and successes with implementation of these pathways. METHODS: A mixed-methods study of Michigan ED leaders was conducted. First, a cross-sectional Web-based survey was distributed via e-mail to all 135 hospital-based EDs in the state. Descriptive statistics were calculated. Survey participants who provided contact information were considered eligible for follow-up. Semistructured interviews were conducted by telephone until thematic saturation was reached. Interviews were recorded, transcribed verbatim, reviewed for accuracy, and thematically coded. Representative quotes were extracted for reporting. RESULTS: Survey responses were received from 64 ED leaders (48% eligible response rate). Semistructured interviews were conducted with a purposeful sample of 11 of the 29 representatives willing to be contacted. Eight sites implemented clinical care pathways as a strategy to reduce avoidable admissions. Pathways were developed for high-frequency conditions. Many pathways were multidisciplinary, incorporating case managers and outpatient care providers, which was thought to improve acceptability. Five models of care emerged 1) standardized care, 2) observation medicine, 3) enhanced follow-up, 4) care coordination, and 5) comprehensive programs. We identified barriers to and facilitators of discharging a patient from the ED when an admission otherwise could be avoided. Barriers included limited access to follow-up, lack of care coordination, and lack of trust in patient's ability to provide self-care or navigate the system. Facilitators included strong relationships with outpatient providers, care coordination, and shared decision making. CONCLUSIONS: Potential solutions to help avoid hospitalization from the ED include multidisciplinary clinical care pathways. Successful pathways emerged from bringing stakeholders from the ED, hospital, and health care community together. Additionally, emergency providers need systems and supports in place to help their patients navigate follow-up care in a timely fashion.

Bad girl and unmet family planning need among Sub-Saharan African adolescents: the role of sexual and reproductive health stigma.

Adolescent pregnancy contributes to high maternal mortality rates in Sub-Saharan Africa. We explored stigma surrounding adolescent sexual and reproductive health (SRH) and its impact on young Ghanaian women's family planning (FP) outcomes. We conducted in-depth, semi-structured interviews with 63 women ages 15-24 recruited from health facilities and schools in Accra and Kumasi, Ghana. Purposive sampling provided diversity in reproductive/relationship/socioeconomic/religious characteristics. Using both deductive and inductive approaches, our thematic analysis applied principles of grounded theory. Participants described adolescent SRH experiences as cutting across five stigma domains. First, community norms identified non-marital sex and its consequences (pregnancy, childbearing, abortion, sexually transmitted infections) as immoral, disrespectful, and disobedient, resulting in bad girl labeling. Second, enacted stigma entailed gossip, marginalization, and mistreatment from all community members, especially healthcare workers. Third, young sexually active, pregnant, and childbearing women experienced internalized stigma as disgrace, shame and shyness. Fourth, non-disclosure and secret-keeping were used to avoid/reduce stigma. Fifth, stigma resilience was achieved through social support. Collectively, SRH stigma precluded adolescents' use of FP methods and services. Our resulting conceptual model of adolescent SRH stigma can guide health service, public health, and policy efforts to address unmet FP need and de-stigmatize SRH for young women worldwide.

Factors associated with sexual and reproductive health stigma among adolescent girls in Ghana.

OBJECTIVE: Using our previously developed and tested Adolescent Sexual and Reproductive Health (SRH) Stigma Scale, we investigated factors associated with perceived SRH stigma among adolescent girls in Ghana. METHODS: We drew upon data from our survey study of 1,063 females 15-24yrs recruited from community- and clinic-based sites in two Ghanaian cities. Our Adolescent SRH Stigma Scale comprised 20 items and 3 sub-scales (Internalized, Enacted, Lay Attitudes) to measure stigma occurring with sexual activity, contraceptive use, pregnancy, abortion and family planning service use. We assessed relationships between a comprehensive set of demographic, health and social factors and SRH Stigma with multi-level multivariable linear regression models. RESULTS: In unadjusted bivariate analyses, compared to their counterparts, SRH stigma scores were higher among girls who were younger, Accra residents, Muslim, still in/dropped out of secondary school, unemployed, reporting excellent/very good health, not in a relationship, not sexually experienced, never received family planning services, never used contraception, but had been pregnant (all p-values <0.05). In multivariable models, higher SRH stigma scores were associated with history of pregnancy (ß = 1.53, CI = 0.51,2.56) and excellent/very good self-rated health (ß = 0.89, CI = 0.20,1.58), while lower stigma scores were associated with older age (ß = -0.17, 95%CI = -0.24,-0.09), higher educational attainment (ß = -1.22, CI = -1.82,-0.63), and sexual intercourse experience (ß = -1.32, CI = -2.10,-0.55). CONCLUSIONS: Findings provide insight into factors contributing to SRH stigma among this young Ghanaian female sample. Further research disentangling the complex interrelationships between SRH stigma, health, and social context is needed to guide multi-level interventions to address SRH stigma and its causes and consequences for adolescents worldwide.

Multiple levels of social influence on adolescent sexual and reproductive health decision-making and behaviors in Ghana.

Little is known about the multilevel social determinants of adolescent sexual and reproductive health (SRH) that shape the use of family planning (FP) among young women in Africa. We conducted in-depth, semi-structured, qualitative interviews with 63 women aged 15-24 years in Accra and Kumasi, Ghana. We used purposive, stratified sampling to recruit women from community-based sites. Interviews were conducted in English or local languages, recorded, and transcribed verbatim. Grounded theory-guided thematic analysis identified salient themes. Three primary levels of influence emerged as shaping young women's SRH experiences, decision-making, and behaviors. Interpersonal influences (peers, partners, and parents) were both supportive and unsupportive influences on sexual debut, contraceptive (non) use, and pregnancy resolution. Community influences included perceived norms about acceptability/unacceptability of adolescent sexual activity and its consequences (pregnancy, childbearing, abortion). Macro-social influences involved religion and abstinence and teachings about premarital sex, lack of comprehensive sex education, and limited access to confidential, quality SRH care. The willingness and ability of young women in our study to use FP methods and services were affected, often negatively, by factors operating within and across each level. These findings have implications for research, programs, and policies to address social determinants of adolescent SRH.

Development and Validation of a Scale to Measure Adolescent Sexual and Reproductive Health Stigma: Results From Young Women in Ghana.

Young women's experiences with sexual and reproductive health (SRH) stigma may contribute to unintended pregnancy. Thus, stigma interventions and rigorous measures to assess their impact are needed. Based on formative work, we generated a pool of 51 items on perceived stigma around different dimensions of adolescent SRH and family planning (sex, contraception, pregnancy, childbearing, abortion). We tested items in a survey study of 1,080 women ages 15 to 24 recruited from schools, health facilities, and universities in Ghana. Confirmatory factor analysis (CFA) identified the most conceptually and statistically relevant scale, and multivariable regression established construct validity via associations between stigma and contraceptive use. CFA provided strong support for our hypothesized Adolescent SRH Stigma Scale (chi-square p value < 0.001; root mean square error of approximation [RMSEA] = 0.07; standardized root mean square residual [SRMR] = 0.06). The final 20-item scale included three subscales: internalized stigma (six items), enacted stigma (seven items), and stigmatizing lay attitudes (seven items). The scale demonstrated good internal consistency (α = 0.74) and strong subscale correlations (α = 0.82 to 0.93). Higher SRH stigma scores were inversely associated with ever having used modern contraception (adjusted odds ratio [AOR] = 0.96, confidence interval [CI] = 0.94 to 0.99, p value = 0.006). A valid, reliable instrument for assessing SRH stigma and its impact on family planning, the Adolescent SRH Stigma Scale can inform and evaluate interventions to reduce/manage stigma and foster resilience among young women in Africa and beyond.

Women's Contraceptive Preference-Use Mismatch.

BACKGROUND: Family planning research has not adequately addressed women's preferences for different contraceptive methods and whether women's contraceptive experiences match their preferences. METHODS: Data were drawn from the Women's Healthcare Experiences and Preferences Study, an Internet survey of 1,078 women aged 18-55 randomly sampled from a national probability panel. Survey items assessed women's preferences for contraceptive methods, match between methods preferred and used, and perceived reasons for mismatch. We estimated predictors of contraceptive preference with multinomial logistic regression models. RESULTS: Among women at risk for pregnancy who responded with their preferred method (n = 363), hormonal methods (non-LARC [long-acting reversible contraception]) were the most preferred method (34%), followed by no method (23%) and LARC (18%). Sociodemographic differences in contraception method preferences were noted (p-values <0.05), generally with minority, married, and older women having higher rates of preferring less effective methods, compared to their counterparts. Thirty-six percent of women reported preference-use mismatch, with the majority preferring more effective methods than those they were using. Rates of match between preferred and usual methods were highest for LARC (76%), hormonal (non-LARC) (65%), and no method (65%). The most common reasons for mismatch were cost/insurance (41%), lack of perceived/actual need (34%), and method-specific preference concerns (19%). CONCLUSION: While preference for effective contraception was common among this sample of women, we found substantial mismatch between preferred and usual methods, notably among women of lower socioeconomic status and women using less effective methods. Findings may have implications for patient-centered contraceptive interventions.

"I don't know enough to feel comfortable using them:" Women's knowledge of and perceived barriers to long-acting reversible contraceptives on a college campus.

OBJECTIVE: To assess multiple dimensions of long-acting reversible contraception (LARC) knowledge and perceived multi-level barriers to LARC use among a sample of college women. STUDY DESIGN: We conducted an Internet-based study of 1982 female undergraduates at a large mid-western university. Our 55-item survey used a multi-level framework to measure young women's understanding of, experiences with intrauterine devices (IUD) and implants and their perceived barriers to LARC at individual, health systems and community levels. The survey included a 20-item knowledge scale. We estimated and compared LARC knowledge scores and barriers using descriptive, bivariate and linear regression statistics. RESULTS: Few college women had used (5%) or heard of (22%) LARC, and most self-reported "little" or "no" knowledge of IUDs (79%) and implants (88%). Women answered 50% of LARC knowledge items correctly (mean 10.4, range 0-20), and scores differed across sociodemographic groups (p values<.04). Factors associated with scores in multivariable models included race/ethnicity, program year, sorority participation, religious affiliation and service attendance, employment status, sexual orientation and contraceptive history. Perceived barriers to IUDs included the following: not wanting a foreign object in body (44%), not knowing enough about the method (42%), preferring a "controllable" method (42%), cost (27%), and not being in a long-term relationship (23%). Implant results were similar. "Not knowing enough" was women's primary reason for IUD (18%) and implant (22%) nonuse. CONCLUSION: Lack of knowledge (both perceived and actual) was the most common barrier among many perceived individual-, systems- and community-level factors precluding these college women's LARC use. Findings can inform innovative, multi-level interventions to improve understanding, acceptability and uptake of LARC on campuses. IMPLICATIONS: Lack of knowledge of IUDs and implants served as a primary barrier to highly effective contraceptive use among these college women. Comprehensive, patient-centered and multi-level educational public health strategies are needed to promote positive campus climates around LARC and improve family planning outcomes among this substantial reproductive-aged population.

U.S. Women's Intended Sources for Reproductive Health Care.

INTRODUCTION: The current sociopolitical climate and context of the Affordable Care Act have led some to question the future role of family planning clinics in reproductive health care. We explored where women plan to get their future contraception, pelvic exam/pap smears, and sexually transmitted infection testing, with a focus on the role of family planning clinics. METHODS: Data were drawn from a study of United States adults conducted in January 2013 from a national online panel. We focused on English-literate women aged 18-45 years who answered items on intended sources of care (private office/health maintenance organization [HMO], family planning clinic, other, would not get care) for reproductive health services. We used Rao-Scott F tests to compare intended sources across sociodemographic groups, and logistic regression to model odds of intending to use family planning clinics. Probability weights were used to adjust for the complex sampling design. RESULTS: The response rate was 61% (n = 2,182). Of the 723 respondents who met the inclusion criteria, approximately half intended to use private offices/HMOs. Among some subgroups, including less educated (less than high school), lower annual incomes (<$25,000) and uninsured women, the proportion intending to use family planning clinics was higher than the proportion intending to use private office/HMO in unadjusted analyses. Across all service types, unmarried and uninsured status were associated with intention to use family planning clinics in multivariable models. CONCLUSIONS: While many women intend to use private offices/HMOs for their reproductive health care, family planning clinics continue to play an important role, particularly for socially disadvantaged women.

Human Papillomavirus Vaccine Uptake After a Tailored, Online Educational Intervention for Female University Students: A Randomized Controlled Trial.

BACKGROUND: Educational interventions may be a strategy to increase human papillomavirus (HPV) vaccination among female university students, but studies to date have shown mixed results. This study evaluated the effect of MeFirst, an individually tailored, online educational intervention, on HPV vaccine-related knowledge, vaccination intention, and uptake among previously unvaccinated female university students. METHODS: All female students aged 18-26 years who reported being unvaccinated against HPV at a midwestern university were invited via email to enroll. Participants completed an online survey that assessed baseline HPV vaccine-related knowledge, attitudes and vaccination intention. Participants (n = 661) were then randomized to receive either an educational website automatically tailored to their baseline survey responses (MeFirst intervention) or a standard CDC information factsheet on HPV vaccine (control). Vaccine uptake and repeat knowledge and attitude measures were assessed with online surveys 3 months following the intervention and analyzed using logistic regression models. RESULTS: HPV vaccine uptake was similar in both the MeFirst and control groups at 3 months following the intervention (p = 0.98). Three months after the intervention, the proportion of participants with high knowledge regarding HPV vaccination increased from baseline (32% to 50%; p < 0.0001) but the proportion with favorable intention was unchanged. CONCLUSIONS: We found that an individually tailored, online educational tool had similar effects as a nontailored factsheet on HPV-related knowledge, intention to HPV undergo vaccination, and HPV vaccine uptake among previously unvaccinated female university students.

Social, Reproductive, and Attitudinal Factors Associated with U.S. Women's Disagreement with the Passage of the Affordable Care Act.

BACKGROUND: Notably absent from research and public and policy dialogue on the Affordable Care Act (ACA) and reproductive health care are women's perspectives and a broader understanding of factors that shape ACA attitudes. We investigated social, reproductive, and attitudinal factors associated with women's disagreement with the passage of the ACA. METHODS: Data were drawn from the Women's Health Care Experiences and Preferences Study, our population-based internet survey of 1,078 randomly sampled United States women ages 18-55 years conducted in September 2013. Items measured ACA attitudes, including disagreement with the ACA's passage. We examined relationships between ACA disagreement, sociodemographic and reproductive characteristics, health service experiences, and reproductive health care and policy attitudes with logistic regression. RESULTS: Among women who had heard of the ACA (n=888), 35% disagreed with it and 38% did not know how they felt. Black women (adjusted odds ratio [aOR] 0.12, 95% confidence interval [CI] 0.03-0.55) and women with incomes of >$75k (aOR 0.38, CI 0.17-0.88), Medicare/Medicaid insurance (aOR 0.24, CI 0.10-0.61), and infrequent religious service attendance (aOR 0.57, CI 0.35-0.93) were less likely to disagree with the ACA's passage, compared with their counterparts. Republican party affiliation was the strongest predictor of ACA disagreement (aOR 17.10, CI 9.12-32.09). Negative beliefs about the ACA's ability to improve access to preferred care and regarding employers' and the government's roles in reproductive health care were positively associated with ACA disagreement. CONCLUSIONS: Many women who could benefit from the ACA disagree with or do not know how they feel about its passage, which may influence participation in ACA benefits and services.

A population-based study of US women's preferred versus usual sources of reproductive health care.

OBJECTIVE: We characterized US women's preferred and usual sources of reproductive health care. STUDY DESIGN: Data were drawn from the Women's Health Care Experiences and Preferences Study, an Internet survey of 1078 women aged 18-55 years randomly sampled from a national probability panel. We described and compared women's preferred and usual sources of care (women's health specialists including obstetricians-gynecologists and family-planning clinics, primary care, other) for Papanicolaou/pelvic examination, contraception, and sexually transmitted infection (STI) services using χ(2), logistic regression, and kappa statistics. RESULTS: Among women reporting health service utilization (n = 984, 92% overall; 77% Papanicolaou/pelvic; 33% contraception; 8% STI), women's health specialists were the most used sources of care for Papanicolaou/pelvic (68%), contraception (74%), and STI (75%) services. Women's health specialists were also the most preferred care sources for Papanicolaou/pelvic (68%), contraception (49%), and STI (35%) services, whereas the remainder of women preferred primary care/other sources or not to get care. Differences in preferred and usual care sources were noted across sociodemographic groups, including insurance status and income level (P < .05). Preference for women's health specialists was the strongest predictor of women's health specialist utilization for Papanicolaou/pelvic (adjusted odds ratio, 48.8; 95% confidence interval, 25.9-91.8; P < .001) and contraceptive (adjusted odds ratio, 194.5; 95% confidence interval, 42.3-894.6; P < .001) services. Agreement between preferred and usual-care sources was high for Papanicolaou/pelvic (85%, kappa, 0.63) and contraception (86%; kappa, 0.64) services; disagreement (range, 15-22%) was associated with insurance, employment, income, race, and religion (P < .05). CONCLUSION: Women's preferences for and use of women's health specialists for reproductive health care has implications for efforts to define the role of obstetricians-gynecologists and family planning clinics in current health systems.

Beyond usual care: the economic consequences of expanding treatment options in early pregnancy loss.

OBJECTIVE: The objective of this study was to estimate the economic consequences of expanding options for early pregnancy loss (EPL) treatment beyond expectant management and operating room surgical evacuation (usual care). STUDY DESIGN: We constructed a decision model using a hypothetical cohort of women undergoing EPL management within a 30 day horizon. Treatment options under the usual care arm include expectant management and surgical uterine evacuation in an operating room (OR). Treatment options under the expanded care arm included all evidence-based safe and effective treatment options for EPL: expectant management, misoprostol treatment, surgical uterine evacuation in an office setting, and surgical uterine evacuation in an OR. Probabilities of entering various treatment pathways were based on previously published observational studies. RESULTS: The cost per case was US $241.29 lower for women undergoing treatment in the expanded care model as compared with the usual care model (US $1033.29 per case vs US $1274.58 per case, expanded care and usual care, respectively). The model was the most sensitive to the failure rate of the expectant management arm, the cost of the OR surgical procedure, the proportion of women undergoing an OR surgical procedure under usual care, and the additional cost per patient associated with implementing and using the expanded care model. CONCLUSION: This study demonstrates that expanding women's treatment options for EPL beyond what is typically available can result in lower direct medical expenditures.

Receipt of prescription contraception by commercially insured women with chronic medical conditions.

OBJECTIVE: To assess differences in receipt of prescription contraception among women with and without chronic medical conditions. METHODS: This observational study used 3 years of administrative claims records for insured women aged 21-45 years who were enrolled in a commercial insurance company in Michigan between 2004 and 2009. Women were considered to have a chronic medical condition if they had at least two claims for one of the following conditions, in order of prevalence in our study population: hypertension, asthma, hypothyroidism, diabetes, obesity, rheumatoid arthritis, inflammatory bowel disease, or systemic lupus erythematosus. Our primary outcome was receipt of prescription contraception, defined by a pharmacy claim or diagnostic or procedural code. We used multivariable logistic regression to estimate the association of chronic condition status with the odds of receiving prescription contraception within 3 years adjusting for age, community-level socioeconomic status, total outpatient visits, and cervical cancer screening. RESULTS: Of 11,649 women studied, 16.0% (n=1,862) had at least one of the chronic conditions we considered. Of those with a chronic condition, 33.5% (n=623) received prescription contraception during the 3-year study period compared with 41.1% (n=4,018) of those without a chronic condition (P<.001). After adjusting for covariates, women with a chronic condition remained less likely than women without a chronic condition to have received prescription contraception (adjusted odds ratio 0.85, 95% confidence interval 0.76-0.96, P=.010). CONCLUSION: Despite a greater risk for adverse outcomes with an unplanned pregnancy, women with these chronic conditions were less likely to receive prescription contraception. LEVEL OF EVIDENCE: III.

Human papillomavirus vaccine stages of change among male and female university students: ready or not?

OBJECTIVE: To examine gender differences in human papillomavirus (HPV) vaccine stages of change following the recommendations for permissive use of HPV vaccine in males. PARTICIPANTS: Students aged 18-26 attending a large, public, Midwest university in April 2010. METHODS: Participants completed a self-administered, online questionnaire. HPV vaccine stage of change was assessed according to core constructs of the Transtheoretical Model of Behavior Change. Logistic regression was used to identify associations of HPV-related beliefs and attitudes with stage of change. RESULTS: Although most (80.5%) of the 4,019 participants had at least contemplated HPV vaccination, more females had taken observable steps towards vaccination. Significant differences between genders in HPV-related beliefs and attitudes were observed, particularly perceived parental or perceived health care provider approval of HPV vaccination. CONCLUSIONS: University students generally agreed with the benefits of HPV vaccination, both for themselves and for society, and these attitudes were significantly associated with having at least contemplated vaccination.

Feasibility of LNG-IUS in a baboon model.

BACKGROUND: The baboon (Papio hamadryas anubis) is an attractive model for intrauterine contraception research due to anatomic similarity to the human. Although non-human primates have previously been used for intrauterine contraception research, it was unknown whether modern intrauterine devices (IUDs) can be placed in an anatomically similar position in the baboon. This study sought to determine whether human-use IUDs could be seated correctly in the uterus of the baboon. STUDY DESIGN: The levonorgestrel-releasing intrauterine system (LNG-IUS) was placed ex vivo into two baboon uteri collected at necropsy and in three living, reproductively proven baboons. RESULTS: Correct placement of human-use IUDs in the baboon was confirmed by both MRI and ultrasound. This study establishes that a LNG-IUS can be inserted into the baboon uterus and maintained without clinically adverse effects for at least 6 months. The positioning of the device is similar to positioning found in women. CONCLUSION: These findings provide important support for studying IUD safety and efficacy in the baboon.

Economic cost of fecal incontinence.

BACKGROUND: Despite its prevalence and deleterious impact on patients and families, fecal incontinence remains an understudied condition. Few data are available on its economic burden in the United States. OBJECTIVE: The aim of this study was to quantify per patient annual economic costs associated with fecal incontinence. DESIGN: A mail survey of patients with fecal incontinence was conducted in 2010 to collect information on their sociodemographic characteristics, fecal incontinence symptoms, and utilization of medical and nonmedical resources for fecal incontinence. The analysis was conducted from a societal perspective and included both direct and indirect (ie, productivity loss) costs. Unit costs were determined based on standard Medicare reimbursement rates, national average wholesale prices of medications, and estimates from other relevant sources. All cost estimates were reported in 2010 US dollars. SETTINGS: This study was conducted at a single tertiary care institution. PATIENTS: The analysis included 332 adult patients who had fecal incontinence for more than a year with at least monthly leakage of solid, liquid, or mucous stool. MAIN OUTCOME MEASURES: The primary outcome measured was the per patient annual economic costs associated with fecal incontinence. RESULTS: The average annual total cost for fecal incontinence was $4110 per person (median = $1594; interquartile range, $517-$5164). Of these costs, direct medical and nonmedical costs averaged $2353 (median, $1176; interquartile range, $294-$2438) and $209 (median, $75; interquartile range, $17-$262), whereas the indirect cost associated with productivity loss averaged $1549 per patient annually (median, $0; interquartile range, $0-$813). Multivariate regression analyses suggested that greater fecal incontinence symptom severity was significantly associated with higher annual direct costs. LIMITATIONS: This study was based on patient self-reported data, and the sample was derived from a single institution. CONCLUSIONS: Fecal incontinence is associated with substantial economic cost, calling for more attention to the prevention and effective management of this condition.

The effects of a single cervical inoculation of Chlamydia trachomatis on the female reproductive tract of the baboon (Papio anubis).

BACKGROUND: The baboon (Papio hamadryas anubis) can be transcervically instrumented, facilitating studies of intrauterine contraception and reproductive tract infection. We sought to determine if the baboon could become infected with a single cervical inoculation of Chlamydia trachomatis. METHODS: Ten female baboons were randomized and inoculated cervically with C. trachomatis serovar E (or buffer alone). Animals underwent weekly clinical and laparoscopic evaluations for four weeks and at post-inoculation week 8, to monitor upper tract infection. Cervical culture and nucleic acid amplification testing (NAAT) were completed weekly throughout the study. Animals were euthanized at week 16 and the reproductive tracts were examined histologically. RESULTS: All inoculated animals developed cervical infection. The average duration of positive NAAT results was 6.8 weeks (range 2-16). Two of eight (25%) animals tested positive from fallopian tube samples. Infected animals showed histological findings consistent with chlamydial infection, such as germinal centers. Five of ten animals seroconverted to C. trachomatis. CONCLUSIONS: Baboons cervically inoculated once with C. trachomatis develop infection similar to humans, with a low incidence of upper tract infection. This novel model of Chlamydia infection closely resembles human disease and opens new avenues for studying the pathogenesis of sexually transmitted infections and contraceptive safety.

Nonhuman primate models used to study pelvic inflammatory disease caused by Chlamydia trachomatis.

Pelvic inflammatory disease (PID) is a global health concern that is associated with significant morbidity and is a major cause of infertility. Throughout history animals have been used for anatomical studies and later as models of human disease. In particular, nonhuman primates (NHPs) have permitted investigations of human disease in a biologically, physiologically, and anatomically similar system. The use of NHPs as human PID models has led to a greater understanding of the primary microorganisms that cause disease (e.g., Chlamydia trachomatis and Neisseria gonorroheae), the pathogenesis of infection and its complications, and the treatment of people with PID. This paper explores historical and contemporary aspects of NHP modeling of chlamydial PID, with an emphasis on advantages and limitations of this approach and future directions for this research.