Understanding the Impacts of the Supreme Court Case FDA v Alliance for Hippocratic Medicine.

This Viewpoint outlines the potential effects of the Supreme Court case regarding mifepristone restrictions: a decision for the FDA would allow current dispensing, while ruling against the FDA would severely curtail access to reproductive health options.

Implementation of pharmacy access to hormonal contraception.

BACKGROUND: States throughout the country are enacting legislation to authorize pharmacist prescribing of hormonal contraception to decrease barriers to access. Little is known about the process of state implementation of pharmacist prescriptive authority for hormonal contraception. OBJECTIVES: To understand the state-level steps to enable pharmacist prescribing of hormonal contraception, including implementation challenges and facilitators. METHODS: We conducted a qualitative study of interviews with 18 key individuals, including pharmacists and other stakeholders, from ten states with laws permitting pharmacist-prescribed hormonal contraception from March 2021 to April 2022. We analyzed data using directed qualitative analysis principles and compared experiences across states. We organized the data using the Consolidated Framework for Implementation Research framework and evaluated relevant constructs in states' implementation efforts. RESULTS: Participants identified four key steps to implement pharmacist prescribing at the state level, including development of state rules and regulations, educational programs, reimbursement mechanisms, and expansion strategies to pharmacists and pharmacies. Participants identified early involvement of key stakeholders and a culture of support for clinical pharmacists as facilitators to implementation. Challenges included complexity and cost of billing mechanisms, lack of funding for implementation efforts, and competing priorities of pharmacies/pharmacists. CONCLUSION: Participants in states with pharmacist prescriptive authority for hormonal contraception identified development of reimbursement and billing mechanisms as the most critical state-level step in implementation. Focusing on facilitators of key steps can guide states in developing successful implementation strategies to improve contraceptive access.

A statement on abortion by 900 professors of obstetrics and gynecology after the reversal of Roe vWade.

In the American Journal of Obstetrics and Gynecology in 1972 and 2013, 100 leaders in obstetrics and gynecology wrote calls to action-in 1972 in anticipation of the Roe v Wade decision and in 2013 in concern over the increasing restrictions to abortion care. In this article, 900 professors support a call to action for reinstating federal protections for abortion. Over a year ago, the Supreme Court handed down the Dobbs decision, overturning nearly 50 years of precedent in retracting the constitutionally protected right to abortion. The medical community is already seeing the harms of this decision on the lives and health of our patients and on the ability to train upcoming physicians in this medically necessary evidence-based care. Further harms are anticipated, including negative effects on maternal mortality. The 900 professors of obstetrics and gynecology whose signatures appear at the conclusion of this article stand together in support of reproductive freedom, including the right to affordable, accessible, safe, and legal abortion care.

Now is the time to stand up for reproductive justice and abortion access.

The ongoing assault on abortion care in the United States culminating in the Supreme Court decision that overturned Roe v Wade calls for concerted national action to address the major gaps in care and training that will ensue. We write this call to action to our community of obstetrician-gynecologists to prioritize advocacy for access to abortion care. Professional health organizations understand the importance of access to contraception and abortion care as the foundation for reproductive health, autonomy, and empowerment. As restrictions proliferate, patients are encountering significant challenges in accessing care; all in our community who provide obstetrical and gynecologic care need to step up to ensure adequate and equitable patient care and provider training. In this Clinical Opinion, we outline current professional organization evidence-based support for comprehensive reproductive health care including abortion care, without interference by politics, strategies to proactively prevent further restrictions, and actions to mitigate the harm that will be caused by further restrictions to abortion care. We must all speak up, be visible in our support, and take any and every opportunity to advocate for abortion care as an integral part of comprehensive reproductive medical care.

Physicians and healthcare professionals as advocates for abortion care and reproductive choice.

PURPOSE OF REVIEW: The current review discusses the overarching role of advocacy as a primary component of access to abortion care. Abortion is viewed differently from any other form of health care, resulting in a marginalized, but essential healthcare component: without ongoing effective and strategic advocacy, abortion will not become or remain available. Lack of access to abortion care disproportionately affects historically excluded communities. RECENT FINDINGS: Advocacy is core to the provision of sexual and reproductive health. The antiabortion community has effectively used policy to achieve long-term goals of severely restricting access to abortion. Crisis pregnancy centers, the COVID-19 pandemic, and the antiabortion legislation of 2022 have exacerbated existing health inequities. Community engagement and advocacy skills assist providers to support access and combat inequities. Provider and trainee education, interprofessional collaboration, and leadership are critical in the effort to support comprehensive reproductive health care. SUMMARY: Through this literature review and our lived experiences as abortion providers, we assert the importance of healthcare professionals as advocates for abortion rights and services. The need for advocacy crosses specialties and communities; together we are stronger advocates as we continue to support and fight for access to safe legal and equitable abortion care.

Perspectives on pharmacy access to hormonal contraception among rural New Mexico women.

OBJECTIVE: In 2017, New Mexico approved an amendment allowing pharmacists to prescribe and dispense hormonal contraception. We interviewed rural New Mexico women to determine their perceptions of pharmacy access to hormonal contraception. STUDY DESIGN: We conducted semi-structured telephone interviews with women recruited from rural New Mexico communities. The interview guide explained the amendment followed by questions about the advantages and disadvantages of pharmacy access to hormonal contraception within rural communities. RESULTS: Between November 2017 and May 2018, we recruited 32 women to participate. Participants were young (26/32 18-29 years old), gravid (27/31), employed (30/32), white (22/32) and Hispanic (26/31). The majority used Medicaid as their primary insurance (16/28). Most participants were supportive of pharmacy access to hormonal contraception. Participants saw their rural communities as facing health care barriers, some of which could be alleviated by pharmacy access. Perceived benefits of pharmacy access included convenience of pharmacy hours, shorter wait times, and no need for an appointment. Participants expressed concerns about lack of privacy in their pharmacies. Many expressed trust in their pharmacist to review side effects and explain usage of contraception- a role that was considered separate from that of a primary care provider who offers regular medical visits for routine screening and nuanced or complex discussions about contraception. Some participants expressed that pharmacy access could be especially beneficial for teens. CONCLUSIONS: Rural New Mexico women were supportive of pharmacy access to contraception and accept pharmacists as trusted members of the health care team. IMPLICATIONS: Rural New Mexico women find benefit in pharmacy access to hormonal contraception, citing improved access to contraceptives in their communities.

Comparison of levonorgestrel level and creamatocrit in milk following immediate versus delayed postpartum placement of the levonorgestrel IUD.

BACKGROUND: Breastfeeding and postpartum contraception critically influence infant and maternal health outcomes. In this pilot study, we explore the effects of timing and duration of postpartum levonorgestrel exposure on milk lipid and levonorgestrel content to establish baseline data for future research. METHODS: This sub-study recruited a balanced convenience sample from 259 participants enrolled in a parent randomized controlled trial comparing immediate to delayed (4-8 weeks) postpartum levonorgestrel IUD placement. All planned to breastfeed, self-selected for sub-study participation, and provided the first sample at 4-8 weeks postpartum (before IUD placement for the delayed group) and the second four weeks later. We used the Wilcoxon rank sum (inter-group) and signed rank (intra-group) tests to compare milk lipid content (creamatocrit) and levonorgestrel levels between groups and time points. RESULTS: We recruited 15 participants from the immediate group and 17 from the delayed group with 10 and 12, respectively, providing both early and late samples. Initially, median levonorgestrel concentration of the immediate group (n = 10) (32.5 pg/mL, IQR: 24.8, 59.4) exceeded that of the delayed group (n = 12) (17.5 pg/mL, IQR: 0.0, 25.8) (p = 0.01). Four weeks later, the values aligned: 26.2 pg/mL (IQR: 20.3, 37.3) vs. 28.0 pg/mL (IQR: 25.2, 40.8). Creamatocrits were similar between both groups and timepoints. CONCLUSIONS: Immediate postpartum levonorgestrel IUD placement results in steady, low levels of levonorgestrel in milk without apparent effects on lipid content. These findings provide initial support for the safety of immediate postpartum levonorgestrel IUD initiation, though the study was not powered to detect noninferiority between groups. TRIAL REGISTRATION: This randomized controlled trial was registered with ClinicalTrials.gov (Registry No. NCT01990703) on November 21, 2013.

Pharmacists' perspectives and experience prescribing hormonal contraception in rural and urban New Mexico.

BACKGROUND: Pharmacist prescription of contraception is becoming increasingly common in the United States (US). Limited information exists on whether this is improving access to contraception in underserved areas, including rural America. OBJECTIVE: We sought to determine whether there were differences by rural location in pharmacists' willingness to prescribe hormonal contraception and perceived barriers to doing so. METHODS: We conducted a cross-sectional survey of pharmacists eligible to prescribe hormonal contraception in New Mexico in March and May 2020. The survey consisted of demographic data, pharmacists' experience prescribing hormonal contraception, and questions regarding perceived barriers to pharmacist-prescribed hormonal contraception. Descriptive statistics assessed differences in survey responses between rural and urban pharmacists. We used multivariable logistic regression to estimate the association between rural practice and prescribing hormonal contraception. RESULTS: Our sampling frame consisted of 822 licensed pharmacists. We received 256 responses, for a response rate of 31.1%. We found that rural pharmacists were as likely as their urban counterparts to prescribe hormonal contraception (adjusted odds ratio 1.22 [95% CI 0.56-2.68], P = 0.50). Five main barriers included a need for additional training, reimbursement for services, liability concerns, corporate policies, and shortage of staff. No difference in barriers were identified by rural location or staff role. CONCLUSION: Pharmacy access has the potential to improve access to contraception across New Mexico, including underserved rural areas.

A 50-Year Commitment to American Indian and Alaska Native Women.

Since 1970, the American College of Obstetricians and Gynecologists' Committee on American Indian and Alaska Native Women's Health has partnered with the Indian Health Service and health care facilities serving Native American women to improve quality of care in both rural and urban settings. Needs assessments have included formal surveys, expert panels, consensus conferences, and onsite program reviews. Improved care has been achieved through continuing professional education, recruitment of volunteer obstetrician-gynecologists, advocacy, and close collaboration at the local and national levels. The inclusive and multifaceted approach of this program should provide an effective model for collaborations between specialty societies and health care professionals providing primary care services that can reduce health disparities in underserved populations.

Traveling for rights: Abortion trends in New Mexico after passage of restrictive Texas legislation.

OBJECTIVES: To determine the proportion of abortions provided to patients from Texas in New Mexico before and after the 2013 enactment of Texas House Bill 2 (HB2), an omnibus bill of abortion restrictions, and to compare the gestational ages at which Texans presented for abortion in New Mexico before and after HB2. STUDY DESIGN: We conducted a chart review of Texas and New Mexico patients obtaining an abortion in New Mexico abortion clinics before HB 2 was signed and implemented (time period 1: January 1, 2012 to December 31, 2012) and after HB 2 went into effect (time period 2: May 1, 2014 to April 30, 2015). We used random sampling of corresponding 7-day periods (by week number during the one-year sample) to obtain data until we reached the desired sample of at least 300 patients. We compared proportions of individuals from Texas obtaining abortions and the gestational age at which they presented in the two time periods. RESULTS: We abstracted data from 350 and 300 Texas and New Mexico patients, respectively. The proportion of procedures provided to women from Texas increased from 10 (3%) pre-HB2 to 43 (14%) post-HB2 (p < 0.0001). The proportion of procedures in Texas patients at 13 to ≤24 weeks increased from 1 of 29 (3%) pre-HB2 to 10 of 38 (26%) post-HB2 (p = 0.012). CONCLUSION: The proportion of Texans scheduling abortions in New Mexico within the first 24 weeks of gestation increased after passage of HB2. Restrictive legislation may force more people to travel across state lines to obtain abortion care. IMPLICATIONS: Patients residing in Texas and seeking abortion care in Texas experienced barriers to abortion care, likely related to restrictions imposed by HB2.

Perspectives on prescribing hormonal contraception among rural New Mexican pharmacists.

OBJECTIVES: New Mexico is a large rural state with high rates of unintended pregnancy and limited access to contraception. In 2017, the New Mexico Pharmacist Prescriptive Authority Act was amended to allow pharmacists to prescribe hormonal contraception. We explored pharmacist perspectives on prescribing hormonal contraceptives, including perceived barriers and facilitators to implementation in rural New Mexico and opinions on over-the-counter (OTC) access, and prescribing and inserting subdermal contraceptive implants. METHODS: This qualitative study recruited rural pharmacists using contact information from the New Mexico Board of Pharmacy and at a state-level pharmacist conference. We conducted semistructured telephone interviews with pharmacists focusing on benefits and concerns about prescribing hormonal contraception, resources required, perspectives on OTC access, and interest in prescribing and placing contraceptive implants. Deidentified transcribed interviews were analyzed by 2 independent coders for emerging themes. RESULTS: From November 2017 to January 2018, we recruited 25 rural pharmacists and conducted 21 interviews. The majority of participants were male (71%), aged over 60 years (43%), and in practice for over 20 years (52%). Interviewees were mostly positive about prescribing hormonal contraception citing community benefits. The top 3 perceived barriers were training needs, reimbursement, and liability. The top 3 facilitators were the availability of private areas within pharmacies, pharmacists' role as knowledgeable health care team members, and pharmacist accessibility without appointments. Most pharmacists did not support OTC access to hormonal contraception, and over half were interested in certification to prescribe and place subdermal contraceptive implants. CONCLUSION: New Mexico pharmacists identified community benefits of pharmacy access to hormonal contraception and were interested in training. Several barriers must be addressed to realize the potential of this practice expansion.

An initiative to implement immediate postpartum long-acting reversible contraception in rural New Mexico.

BACKGROUND: Over the past decade, many states have developed approaches to reimburse for immediate postpartum long-acting reversible contraception. Despite expanded coverage, few hospitals offer immediate postpartum long-acting reversible contraception. OBJECTIVES: Immediate postpartum long-acting reversible contraception implementation is complex and requires a committed multidisciplinary team. After New Mexico Medicaid approved reimbursement for this service, the New Mexico Perinatal Collaborative developed and initiated an evidence-based implementation program containing several components. We sought to evaluate timing of the implementation process and facilitators and barriers to immediate postpartum long-acting reversible contraception in several New Mexico rural hospitals. The primary study outcome was time from New Mexico Perinatal Collaborative program component introduction in each hospital to the hospital's completion of the corresponding implementation step. Secondary outcomes included barriers and facilitators to immediate postpartum contraception implementation. STUDY DESIGN: In this mixed-methods study, conducted from April 2017 to May 2018, we completed semistructured questionnaires and interviews with 20 key personnel from 7 New Mexico hospitals that planned to implement immediate postpartum long-acting reversible contraception. The New Mexico Perinatal Collaborative introduced program components to hospitals in a stepped-wedge design. Participants contributed baseline and follow-up data at 4 time periods detailing the steps taken towards program implementation and the timing of step completion at their hospital. Qualitative data were analyzed using directed qualitative content analysis principles based on the Consolidated Framework for Implementation Research. RESULTS: Investigators conducted 43 interviews during the 14-month study period. Median time to complete steps toward implementation-patient education, clinician training, nursing education, charge capture, available supplies, and protocols or guidelines-ranged from 7 days for clinician training to 357 days to develop patient education materials. Facilitators of immediate postpartum contraception readiness were local hospital clinical champions and institutional administrative and financial stability. Of the 7 hospitals, 4 completed all Perinatal Collaborative implementation program components and 3 of those piloted immediate postpartum long-acting reversible contraception services. Two publicly funded hospitals currently offer immediate postpartum long-acting reversible contraception without verification of payment for the device or insertion. The third hospital piloted the program with 8 contraceptive devices, did not receive reimbursement due to identified flaws in Medicaid billing guidance and does not currently offer the service. The remaining 3 of the 7 hospitals declined to complete the NMPC program; the hospital that completed the program but did not pilot immediate postpartum long-acting reversible contraception did so because Medicaid billing mechanisms were incompatible with their automated billing systems. Participants consistently reported that lack of reimbursement was the major barrier to immediate postpartum long-acting reversible contraception implementation. CONCLUSION: Despite the New Mexico Perinatal Collaborative's robust implementation process and hospital engagement, most hospitals did not offer immediate postpartum long-acting reversible contraception over the study period. Reimbursement obstacles prevented full service implementation. Interventions to improve immediate postpartum long-acting reversible contraception access must begin with implementation of seamless billing and reimbursement mechanisms to ensure adequate hospital payments.

Universal access to contraception: women, families, and communities benefit.

Universal access to contraception benefits society: unintended pregnancies, maternal mortality, preterm birth, abortions, and obesity would be reduced by increasing access to affordable contraception. Women should be able to choose when and whether to use contraception, choose which method to use, and have ready access to their chosen method. State and national government should support unrestricted access to all contraceptives. As obstetrician-gynecologists, we have a critical mandate, based on principle and mission, to step up with leadership on this vital medical and public health issue, to improve the lives of women, their families, and society. The field of Obstetrics and Gynecology must provide the leadership for moving forward. The American Gynecological and Obstetrical Society (AGOS), representing academic and public policy leaders from across all disciplines of Obstetrics and Gynecology, is well positioned to serve as a unifying organization, focused on developing a strong unified advocacy voice to fight for accessible contraception for all in the United States.

Obstetrics-gynecology resident long-acting reversible contraception training: the role of resident and program characteristics.

BACKGROUND: Obstetrics-gynecology residents should graduate with competence in comprehensive contraceptive care, including long-acting reversible contraception. Lack of hands-on training and deficits in provider education are barriers to long-acting reversible contraception access. Identifying the number of long-acting reversible contraception insertions performed by obstetrics-gynecology residents could provide insight into the depth and breadth of long-acting reversible contraception training available to obstetrics-gynecology residents in Accreditation Council for Graduate Medical Education-accredited residency programs. OBJECTIVE: Our study investigates long-acting reversible contraception-specific training in obstetrics-gynecology residency programs across the United States, including the self-reported number of long-acting reversible contraception insertions per resident and the impact of resident demographic characteristics and residency program characteristics on training. STUDY DESIGN: Obstetrics-gynecology residents completed a voluntary electronic survey during the 2016 Council on Resident Education in Obstetrics and Gynecology examination. The survey included resident demographic characteristics and residency program characteristics as well as resident education and training in long-acting reversible contraception (number of intrauterine devices and implants inserted, training in immediate postpartum intrauterine device placement). A binary "long-acting reversible contraception insertion experience" variable dichotomized respondents as having a low level of long-acting reversible contraception insertions (0 implants and/or 10 or fewer intrauterine devices ) or a high level of long-acting reversible contraception insertions (1 or more implants and/or 11 or more intrauterine devices). χ2 tests were used to compare the presence of long-acting reversible contraception insertion experience by postgraduate year, resident demographic characteristics, and residency program characteristics. Adjusted logistic regression was performed to ascertain the independent effects of gender, race/ethnicity (non-Hispanic white vs other), residency program type (university vs community), and residency program geographic region on the likelihood of "low" overall long-acting reversible contraception insertion experience. RESULTS: In total, 5055 obstetrics-gynecology residents completed the survey (85%); analysis included only residents in United States obstetrics-gynecology programs (N=4322). Of the total analytic sample, 1777 (41.2%) had low long-acting reversible contraception insertion experience. As expected, the number of intrauterine device insertions, implant insertions, and overall long-acting reversible contraception experience increased as residents progressed through training. Long-acting reversible contraception insertion experience varied by residency program geographic region: 169 (27.1%) residents in programs in the West had low long-acting reversible contraception insertion experience compared with 498 (39.0%) in the South, 473 (45.3%) in the Midwest, and 615 (46.0%) in the Northeast. Only 152 (14.9%) of all postgraduate year 4 residents had low long-acting reversible contraception insertion experience. Among postgraduate year 4 residents, low long-acting reversible contraception insertion experience was significantly associated racial/ethnic minority status and community-based residency program type (compared with university-based). Postgraduate year 4 residents in programs located in the Northeast and Midwest had 4.25 (95% confidence interval, 2.04-8.85) and 2.75 (95% confidence interval, 1.27-5.97) times the odds of low long-acting reversible contraception experience compared with those in residency programs in the West, even after adjusting for other respondent characteristics and other residency program characteristics. CONCLUSION: Obstetrics-gynecology residents experience a range of long-acting reversible contraception training and insertions, which differed according to resident race/ethnicity and residency program characteristics (program type and geographic region). Residency programs with low long-acting reversible contraception training experience should consider opportunities to improve competence in this fundamental obstetrics-gynecology skill.

Barriers and Solutions to Improve Adolescent Intrauterine Device Access.

Professional organizations agree that adolescents are good candidates for intrauterine device (IUD) use. The American Academy of Pediatrics and the American College of Obstetricians and Gynecologists affirm that IUDs should be considered first-line as contraceptive methods for adolescents. Although the number of teens using IUDs is growing, multiple barriers remain, including systems, and patient- and provider-level obstacles. Only through concerted efforts and a committed action plan will adolescents achieve better access to IUDs.

The importance of access to comprehensive reproductive health care, including abortion: a statement from women's health professional organizations.

Barriers to women's reproductive health care access, particularly for termination of pregnancy, are increasing at the local, regional, and national levels through numerous institutional, legislative, and regulatory restrictions. Lack of access to reproductive health care has negative consequences for women's health. Twelve women's health care organizations affirm their support for access to comprehensive reproductive health care, including abortion.

Nitrous Oxide Compared With Intravenous Sedation for Second-Trimester Abortion: A Randomized Controlled Trial.

OBJECTIVE: To assess whether inhaled nitrous oxide is noninferior to intravenous (IV) sedation for pain control during outpatient surgical abortion between 12 and 16 weeks of gestation. METHODS: We enrolled women undergoing surgical abortion at 12-16 weeks of gestation into a multisite, double-blind clinical trial. Participants were randomized to sedation with nitrous oxide (70% nitrous/30% oxygen) or IV fentanyl (100 micrograms) and midazolam (2 mg). Paracervical block was administered to both groups. The primary outcome measure was immediate postabortion recall of maximum pain on a 100-mm visual analog scale. RESULTS: Between August 2016 and March 2017, we assessed 170 women for eligibility and enrolled 39, 19 in the nitrous group and 20 in the IV sedation group. Seven participants in the nitrous group (36.8%) required conversion to IV sedation for inadequate pain control. No participants in the IV sedation group required additional medication. The proportion of women requiring additional pain control in the nitrous group exceeded our predefined stopping rule. Intention-to-treat analysis demonstrated that immediate postabortion visual analog scale pain scores were lower by 20.1 mm (95% CI 1.6-38.6) in women randomized to IV sedation than in women randomized to nitrous. CONCLUSION: Intravenous sedation is a better choice than inhaled nitrous oxide for pain control in second-trimester abortion. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT02755090.