Preferences and Experiences Regarding Pregnancy Options Counseling in Adolescence and Young Adulthood: A Qualitative Study.

PURPOSE: Perspectives of adolescents and young adults (AYAs) experiencing pregnancy options counseling (POC) are absent from the literature. This study explores AYA experiences and preferences related to POC to inform best practice guidelines. METHODS: We conducted semistructured phone interviews in 2020-2021 among US-based individuals, 18-35 years old, who experienced a pregnancy less than 20 years of age. We performed qualitative descriptive analysis of positive and negative attributes of AYA's experiences with POC. RESULTS: Fifty participants reported 59 pregnancies (16 parenting, 19 abortions, 18 adoptions, three miscarriages) between the ages of 13 and 19 years. Positive attributes of POC experienced included: (1) provider communication that was compassionate, respectful, supportive, and attentive to nonverbal cues; (2) provider neutrality; (3) discussion of all pregnancy options; (4) asking about feelings, choice, life plans, and additional supports; (5) provision of informational materials; and (6) warm handoffs/follow-up facilitation. Negative attributes of POC experienced included: (1) judgmental, impersonal, or absent communication; (2) lack of counseling on all options and/or coercive/directive counseling; (3) insufficient time and supportive resources; and (4) confidentiality concerns. We identified no differences in these perspectives across pregnancy outcomes reported. Participants generally desired counseling about all options, with rare exceptions of ambivalence. DISCUSSION: Individuals who experienced an adolescent pregnancy described similar positive and negative attributes of POC regardless of preferred pregnancy outcome. Their perspectives highlight how crucial interpersonal communication skills are for effective POC for AYA. POC training across health care specialties should emphasize confidential, compassionate, and nonjudgmental care for AYA patients.

Are Illinois Contraceptive Providers Comfortable Providing Care to Adolescents? Results From a Statewide Provider Needs Assessment.

OBJECTIVES: Legislation allows adolescents to access comprehensive contraceptive care; however, provider practices remain unclear. We examined predictors of provider knowledge and comfort surrounding the provision of contraceptive care to adolescents. METHODS: We mailed a survey to Illinois contraceptive providers (n = 251). Study outcomes include 1) knowledge of adolescent consent laws, 2) comfort asking for time alone with adolescents, 3) comfort providing contraception to adolescents without parental consent, and 4) comfort providing long-acting reversible contraception (LARC) to adolescents without parental consent. Using multivariable logistic regression, we estimated adjusted odds ratios (aORs) and 95% confidence intervals (CIs). RESULTS: Most providers are knowledgeable of consent laws (90%) and report being comfortable asking for time alone with adolescents (94%) and comfortable providing contraception to adolescents without parental consent (88%). Having a large proportion of patients who are eligible for family planning services was associated with increased comfort asking for time alone with adolescents (aOR, 7.03; 95% CI, 1.58-31.3) and providing contraception to adolescents (aOR, 4.0; 95% CI, 1.4-11.1). Only one-half (54%) were comfortable providing LARC methods to adolescents, with higher comfort among providers who: received more than 2 days of formal family planning training (aOR, 2.77; 95% CI, 1.2-6.2), specialized in obstetrics-gynecology (aOR, 5.64; 95% CI, 2.1-15.1), and had a patient population with more than 50% patients from minoritized racial/ethnic groups (aOR, 2.9; 95% CI, 1.2-6.6). CONCLUSIONS: Although knowledge of consent laws was high, gaps remain. Only one-half of our sample indicated comfort with the provision of LARC methods without parental consent. Additional efforts to increase provider comfort with all contraceptive methods and training on adolescent-centered practices may be required to meet the needs of adolescent patients.

Health Care and Adoption Service Experiences of People Who Placed Children for Adoption During Adolescence: A Qualitative Study.

STUDY OBJECTIVE: To understand the perspectives of people who placed children for adoption during adolescence DESIGN: We conducted qualitative interviews with adults who placed children for adoption during adolescence. We recruited participants through social media and two adoption-related organizations. We audio-recorded and transcribed interviews. Using thematic analysis, 2 investigators coded the transcripts and identified themes. SETTING: Telephone interviews PARTICIPANTS: Adults ages 18-35 years old who placed children for adoption before they were 20 years old INTERVENTIONS: Semi-structured telephone interviews MAIN OUTCOME MEASURES: Qualitative data RESULTS: We conducted interviews with 18 individuals (median age of 32 years; range 21-35 years). The median age at pregnancy was 18 years (range 13-19 years). Seventeen participants identified as female and one as nonbinary. Themes included the following: (1) Negative experiences with counseling included limited empowerment to make choices about pregnancy or adoption options; (2) negative experiences with counseling included limited information about practical or financial support for pregnant adolescents; (3) negative experiences with the health care system included insensitivity or lack of awareness of the adoption plan at delivery; (4) positive experiences with counseling included comprehensive unbiased options counseling and adoption counseling emphasizing birth parent choice in openness and family placement; (5) positive experiences included longitudinal emotional support during pregnancy, particularly in ways that normalized adoption placement; and (6) participants desired therapy and/or psychological support following adoption placement. CONCLUSIONS: Individuals who chose adoption after adolescent pregnancy described positive and negative encounters with health care and adoption professionals that could serve as targets to improve the overall care experience for this population.

Exploring Illinois contraceptive providers' interest in medication abortion training.

OBJECTIVES: To explore Illinois contraceptive providers' interest in medication abortion training. STUDY DESIGN: We surveyed Illinois contraceptive providers to explore associations between interest in medication abortion training and provider, practice, and patient variables. RESULTS: Of 1040 reachable, eligible contacts, 251 responded to the survey (24% response rate) and more than half (56%) expressed interest in medication abortion training. Providers with the highest interest in medication abortion training were those with <2 days' formal contraceptive training (n = 31; 76%) and those who received Title X funding (n = 32; 81%). CONCLUSION: Findings suggest interest in medication abortion training among Illinois contraceptive providers. IMPLICATIONS: Our findings suggest some contraceptive providers may be interested in training opportunities around medication abortion. More research is needed to understand whether additional training could increase the number of providers able to counsel, refer, and provide medication abortion.

Provider and Patient Perspectives on a New Tangible Decision Aid Tool to Support Patient-Centered Contraceptive Counseling with Adolescents and Young Adults.

STUDY OBJECTIVE: Despite the benefits of patient-centered contraceptive care, many adolescents and young adults do not receive such care. The objective of this study was to develop and evaluate Hello Options, a tangible decision aid to support patient-centered contraceptive counseling with adolescents and young adults in a clinic setting. DESIGN, SETTING, PARTICIPANTS, INTERVENTION, AND MAIN OUTCOME MEASURES: Hello Options is a contraceptive counseling decision aid tool (hereafter referred to as "the Tool") that allows patients to see and feel life-size "tangible" models of the range of contraceptive methods. The Tool was developed by a team of designers, adolescents, clinicians, and researchers using human-centered design. From December 2019 to March 2020, we conducted a pilot study to evaluate the usability, feasibility, and acceptability of the Tool with 10 contraceptive care providers and 40 adolescent and young adult patients (aged 12-29 years) at two Chicago clinics. We calculated descriptive statistics for patient survey data, and qualitatively analyzed provider interview transcripts for salient themes using recursive abstraction. RESULTS: Patients had positive reactions to the Tool, reporting that it allowed them to better understand how contraceptive methods work in their body and that it allowed them to make more informed decisions. Furthermore, providers commented that the Tool facilitated conversations with their patients, helped dispel myths about particular methods, and eased patients' anxieties. Limitations mentioned included storage and portability concerns, and time constraints for counseling. CONCLUSION: Hello Options is a useful, feasible, and acceptable decision aid that can support the provision of patient-centered contraceptive care for young people.

Dual use of condoms with other contraceptive methods among adolescents and young women in the United States.

PURPOSE: To estimate the prevalence of and factors associated with dual method use (i.e., condom with hormonal contraception or an intrauterine device) among adolescents and young women in the United States. METHODS: We used 2006-2010 National Survey of Family Growth data from 2,093 unmarried females aged 15-24 years and at risk for unintended pregnancy. Using multivariable logistic regression, we estimated adjusted odds ratios (aORs) and 95% confidence intervals (CIs) to assess the associations between dual method use at last sex and sociodemographic, behavioral, reproductive history, and sexual behavior factors. RESULTS: At last sex, 20.7% of adolescents and young women used dual methods, 34.4% used condoms alone, 29.1% used hormonal contraception or an intrauterine device alone, and 15.8% used another method or no method. Factors associated with decreased odds of dual method use versus dual method nonuse included having a previous pregnancy (aOR = .44, 95% CI .27-.69), not having health insurance coverage over the past 12 months (aOR = .41, 95% CI .19-.91), and having sex prior to age 16 (aOR = .49, 95% CI .30-.78). CONCLUSIONS: The prevalence of dual method use is low among adolescents and young women. Adolescents and young women who may have a higher risk of pregnancy and sexually transmitted infections (e.g., those with a previous pregnancy) were less likely to use dual methods at last sex. Interventions are needed to increase the correct and consistent use of dual methods among adolescents and young women who may be at greater risk for unintended pregnancy and sexually transmitted infections.

When can a woman have an intrauterine device inserted? A systematic review.

BACKGROUND: Intrauterine device (IUD) insertion during menses may be viewed as preferable by some providers, as it provides reassurance that the woman is not pregnant. However, this practice may result in unnecessary inconvenience and cost to women. The objective of this systematic review is to evaluate the evidence for the effect of inserting IUDs on different days of the menstrual cycle on contraceptive continuation, effectiveness and safety. STUDY DESIGN: We searched the MEDLINE database for peer-reviewed articles published in any language from database inception through March 2012 concerning the effect of inserting copper IUDs (Cu-IUD) or levonorgestrel-releasing IUDs (LNG-IUDs) on different days of the menstrual cycle on contraceptive continuation, effectiveness, and safety. The quality of each individual piece of evidence was assessed using the United States Preventive Services Task Force grading system. RESULTS: We identified eight articles that met the criteria for review. Each study examined the Cu-IUD; no studies were identified that examined the LNG-IUD. Overall, these studies suggest that timing of Cu-IUD insertion has little effect on longer term outcomes (rates of continuation, removal, expulsion, or pregnancy) or on shorter term outcomes (pain at insertion, bleeding at insertion, immediate expulsion). Specifically, there was no evidence to suggest that outcomes were better when Cu-IUD insertions were performed during menses. Limitations of the studies include small sample sizes for insertions performed during later days of the menstrual cycle and non-randomized assignment to timing of insertion. CONCLUSIONS: There is fair evidence (body of evidence grading: II-2, fair) indicating that timing of Cu-IUD insertion has little effect on contraceptive continuation, effectiveness or safety.

Brain damage in preterm newborns and maternal medication: the ELGAN Study.

OBJECTIVE: We sought to evaluate the association between maternal medication use during pregnancy and cerebral white matter damage and cerebral palsy (CP) among very preterm infants. STUDY DESIGN: This analysis of data from the Extremely Low Gestational Age Newborns (ELGAN) Study included 877 infants born <28 weeks' gestation. Mothers were interviewed, charts were reviewed, placentas were cultured and assessed histologically, and children were evaluated at 24 months corrected age. A diagnostic algorithm classified neurologic findings as quadriparetic CP, diparetic CP, hemiparetic CP, or no CP. RESULTS: After adjustment for the potential confounding of disorders for which medications might have been indicated, the risk of quadriparetic CP remained elevated among the infants of mothers who consumed aspirin (odds ratio [OR], 3.0; 95% confidence interval [CI], 1.3-6.9) and nonsteroidal antiinflammatory drugs (NSAIDs) (OR, 2.4; 95% CI, 1.04-5.8). The risk of diparetic CP was also associated with maternal consumption of an NSAID, but only if the consumption was not approved by a physician (OR, 3.5; 95% CI 1.1-11.0). CONCLUSION: The possibility that aspirin and NSAID use in pregnancy could lead to perinatal brain damage cannot be excluded.

Impact of fetal death reporting requirements on early neonatal and fetal mortality rates and racial disparities.

OBJECTIVE: Racial disparities in infant and neonatal mortality vary substantially across the U.S. with some states experiencing wider disparities than others. Many factors are thought to contribute to these disparities, but state differences in fetal death reporting have received little attention. We examined whether such reporting requirements may explain national variation in neonatal and fetal mortality rates and racial disparities. METHODS: We used data on non-Hispanic white and non-Hispanic black infants from the U.S. 2000-2002 linked birth/infant death and fetal death records to determine the degree to which state fetal death reporting requirements explain national variation in neonatal and fetal mortality rates and racial disparities. States were grouped depending upon whether they based the lower limit for fetal death reporting on birthweight alone, gestational age alone, both birthweight and gestational age, or required reporting of all fetal deaths. Traditional methods and the fetuses-at-risk approach were used to calculate mortality rates, 95% confidence intervals, and relative and absolute racial disparity measures in these four groups. RESULTS: States with birthweight-alone fetal death thresholds substantially underreported fetal deaths at lower gestations and slightly overreported neonatal deaths at older gestations. This finding was reflected by these states having the highest neonatal mortality rates and disparities, but the lowest fetal mortality rates and disparities. CONCLUSIONS: Using birthweight alone as a reporting threshold may promote some shift of fetal deaths to newborn deaths, contributing to racial disparities in neonatal mortality. The adoption of a uniform national threshold for reporting fetal deaths could reduce systematic differences in live birth and fetal death reporting.

The effect of body mass index and weight change on epithelial ovarian cancer survival in younger women: a long-term follow-up study.

OBJECTIVE: The objective of this study was to assess the relationship between body mass index (BMI) and epithelial ovarian cancer survival among young women. METHODS: We conducted a cohort analysis of 425 women aged 20-54 years with incident epithelial ovarian cancer enrolled during 1980-1982 in Cancer and Steroid Hormone (CASH), a population-based, case-control study. Participants' vital status was ascertained though linkage with the Surveillance, Epidemiology and End Results (SEER) program. Using Cox proportional hazards models, we estimated adjusted hazard ratios (HR) and 95% confidence intervals (CI) for the association between survival and usual adult BMI, BMI at age 18, and weight change from age 18 to adult. RESULTS: During a follow-up of up to 17 years, 215 women died. Compared to women with an adult BMI in the lowest quartile (<20.7), women in the second (20.8-22.5), third (22.6-24.9), and fourth (≥25.0) quartiles were not at increased risk for death (HR 1.2, 95% CI 0.8-1.8; HR 1.1, 95% CI 0.7-1.6; and HR 0.9, 95% CI 0.6-1.4, respectively) (p trend=0.6). Similarly, neither age 18 BMI nor weight change were associated with ovarian cancer survival. CONCLUSIONS: Although elevated BMI is associated with increased ovarian cancer risk among young women, we found no evidence of its association with ovarian cancer survival in this population.

Health care provider attitudes and practices related to intrauterine devices for nulliparous women.

OBJECTIVE: To examine predictors of health care providers perceiving intrauterine devices (IUDs) as unsafe for nulliparous women and of infrequent provision of IUDs to nulliparous women. METHODS: We analyzed questionnaire data obtained during December 2009 to March 2010 from 635 office-based providers (physicians) and 1,323 Title X clinic providers (physicians, physician assistants, certified nurse midwives, nurse practitioners, and nurses). Using multivariable logistic regression, we estimated adjusted odds ratios (ORs) and 95% confidence intervals (CIs) of the associations between patient, health care provider, and clinic and practice variables and provider misconceptions about the safety of IUDs for nulliparous women and with infrequent IUD provision. RESULTS: Approximately 30% of respondents had misconceptions about the safety of IUDs for nulliparous women. Factors associated with increased odds of misconceptions about the copper IUD and levonorgestrel-releasing IUD included: being an office-based family medicine physician (copper IUD adjusted OR 3.20, 95% CI 1.73-5.89; levonorgestrel-releasing IUD adjusted OR 2.03, 95% CI 1.10-3.76); not being trained in IUD insertion (copper IUD adjusted OR 4.72, 95% CI 2.32-9.61; levonorgestrel-releasing IUD adjusted OR 2.64, 95% CI 1.34-5.22); and nonavailability of IUDs on-site at their practice or clinic (copper IUD adjusted OR 2.18, 95% CI 1.20-3.95; levonorgestrel-releasing IUD adjusted OR 3.45, 95% CI 1.95-6.08). More than 60% of providers infrequently provided IUDs to nulliparous women. Nonavailability of IUDs on-site (copper IUD adjusted OR 1.78, 95% CI 1.01-3.14; levonorgestrel-releasing IUD adjusted OR 2.10, 95% CI 1.22-3.62) and provider misconceptions about safety (copper IUD adjusted OR 6.04, 95% CI 2.00-18.31; levonorgestrel-releasing IUD adjusted OR 6.91, 95% CI 3.01-15.85) were associated with infrequent IUD provision. CONCLUSION: Health care provider misconceptions about the safety of IUDs for nulliparous women are prevalent and are associated with infrequent provision. Improved health care provider education and IUD availability are needed to increase IUD use among nulliparous women. LEVEL OF EVIDENCE: III.