Patient Acceptance of Primary Care Behavioral Health in a Resident Obstetrics and Gynecology Clinic.

OBJECTIVES: Primary care behavioral health (PCBH) is a patient care model in which a behavioral health consultant (BHC) works alongside the primary care provider to address behavioral components of health conditions. PCBH is well received in the primary care setting; however, little is known about acceptability of the service among prenatal patients. The study was designed to explore the acceptability of PCBH among pregnant patients in a resident obstetrics and gynecology clinic. METHODS: A survey designed to assess different components of acceptability was administered to eligible pregnant patients who received prenatal care at the resident obstetrics and gynecology clinic. RESULTS: The majority of patients wanted to receive education on pregnancy-relevant topics from the BHC: healthy weight gain (68.4%), healthy eating (70.4%), healthy exercise (73.5%), and mood disorders (63.3%). The majority of participants wanted help from the BHC in managing coexisting conditions affecting pregnancy: stress (63.3%), depression (75.5%), or anxiety (73%). The majority of patients (55.6%) preferred to work with a BHC for mental health concerns rather than an outside psychiatrist or counselor. PCBH service was perceived to be easy to understand (78%). Barriers to engaging in the PCBH service included time (41.4%), lack of perceived need (13.8%), unavailability (6.9%), and others (13.8%). Despite the perceived benefit, there was an implication of stigma among prenatal patients seeking PCBH or mental health care. CONCLUSIONS: Overall, the PCBH model had high acceptability among a prenatal care population in a resident obstetrics and gynecology clinic and offers potential to improve prenatal outcomes.

A qualitative study of perspectives on research participation among individuals who recently experienced an abortion in Hawai'i.

OBJECTIVES: The United States Code of Federal Regulations mandates extra protections for research involving pregnant participants seeking abortions. This study aims to understand the perspectives of abortion patients regarding recruitment, decision-making, and participation in research. STUDY DESIGN: We recruited adults in Hawai'i who reported at least one induced abortion in the previous 6 months. Recruitment strategies included online advertisements and flyers posted in reproductive health clinics. We conducted in-person, semistructured interviews exploring research preferences. The authors collaboratively reviewed the resulting transcripts and created a code dictionary. We reviewed, organized, condensed, and diagrammed the resulting data to identify dominant themes. RESULTS: Between February and November 2019, we interviewed 25 participants aged 18-41 years who had medication (n = 14) or procedural (n = 11) abortions. Interviews ranged from 32 to 77 minutes (mean = 48 minutes). Four themes emerged: (1) people having abortions are capable of making informed decisions about research participation, (2) abortion-related stigma influences research decision-making, (3) people having abortions prefer to learn about study opportunities early and through participant-driven recruitment methods, and (4) the ideal role of the abortion provider in research is unclear. CONCLUSIONS: Abortion patients in this study want to be informed of research opportunities and feel capable of deciding about participation in research studies. Current federally mandated protections and common research practices could be revisited and revised to better reflect these preferences. IMPLICATIONS: Revision of federal regulations and optimization of recruitment methods may allow researchers to improve the research experience for patients having an abortion.

Society of Family Planning Clinical Recommendation: Emergency contraception.

Emergency contraception (EC) refers to several contraceptive options that can be used within a few days after unprotected or under protected intercourse or sexual assault to reduce the risk of pregnancy. Current EC options available in the United States include the copper intrauterine device (IUD), levonorgestrel (LNG) 52 mg IUD, oral LNG (such as Plan B One-Step, My Way, Take Action), and oral ulipristal acetate (UPA) (ella). These clinical recommendations review the indications, effectiveness, safety, and side effects of emergency contraceptive methods; considerations for the use of EC by specific patient populations and in specific clinical circumstances and current barriers to emergency contraceptive access. Further research is needed to evaluate the effectiveness of LNG IUDs for emergency contraceptive use; address the effects of repeated use of UPA at different times in the same menstrual cycle; assess the impact on ovulation of initiating or reinitiating different regimens of regular hormonal contraception following UPA use; and elucidate effective emergency contraceptive pill options by body mass indices or weight.

Physician's Knowledge and Practices Surrounding Low-Dose Aspirin for Preeclampsia Risk Reduction.

OBJECTIVE: Preeclampsia is a leading cause of pregnancy-related deaths. Up to 60% of maternal deaths associated with preeclampsia may be prevented. Clinical trials have shown that low-dose aspirin reduces preeclampsia up to 30% among women at increased risk. Since 2014, multiple professional societies and the U.S. Preventive Services Task Force have released guidelines on the use of low-dose aspirin to reduce the risk of preeclampsia. We aimed to evaluate physician's knowledge and practices surrounding low-dose aspirin for preeclampsia risk reduction. STUDY DESIGN: We distributed an anonymous electronic survey to licensed physicians in the Rio Grande Valley of Texas who provide prenatal care, including general obstetrician-gynecologists, maternal fetal medicine subspecialists, and family medicine physicians. The survey consisted of 20 items assessing demographics, provider practices, and knowledge on the use of low-dose aspirin for preeclampsia risk reduction. RESULTS: We received 48 surveys with a response rate of 55%. More than 90% of physicians reported recommending low-dose aspirin for preeclampsia risk reduction, of which 98% correctly identified the dose. Of the physicians recommending aspirin, 83% initiate dosing between 12 and 16 weeks, but only 52% continue it until the day of delivery. Nearly 80% of respondents identified that one high-risk factor for preeclampsia is an indication for prophylaxis, but only 56% identified that two or more moderate risk factors should prompt aspirin recommendation. CONCLUSION: Despite clear professional guidelines, physicians demonstrated gaps in knowledge and differences in practices. Enhancing screening tools to assess patient's risk of developing preeclampsia and tailored medical education on moderate risk factors are needed to identify patients who may benefit from this intervention. Increasing the use of aspirin in patients at risk is critical given the benefits of low-dose aspirin in the reduction of poor maternal and neonatal outcomes related to preeclampsia. KEY POINTS: · Low-dose aspirin reduces preeclampsia in patients up to 30%.. · Physicians have gaps in knowledge despite guidelines.. · Following guidelines reduces poor outcomes associated with preeclampsia..

Fetal tissue donation for research at the time of abortion: A qualitative study of individuals who experienced an abortion in Hawaii in 2018-19.

OBJECTIVES: This qualitative study explores how individuals recently experiencing abortions feel about donating fetal tissue for research. In addition, we sought to identify motivating or discouraging factors that influence decision making for these individuals. STUDY DESIGN: We recruited individuals living in Hawaii who reported undergoing an abortion in the previous 6 months for one-on-one semi-structured interviews as part of a broader study investigating views on peri-abortion research practices and protections. We devoted approximately 15 minutes of each 1-hour interview to discussing the donation of aborted fetal tissue for research. We double coded transcribed interviews and identified themes related to fetal tissue donation. RESULTS: We interviewed 25 respondents and identified 4 themes. (1) Individuals viewed fetal tissue donation as an opportunity to help others. (2) Respondents preferred for aborted fetal tissue to be used rather than discarded. (3) Respondents viewed the fetal tissue to be an extension of themselves, so informed consent is critical. (4) Information found online promotes mistrust of fetal tissue handling. CONCLUSIONS: Individuals who have had an abortion are open to fetal tissue donation for research purposes. Pre-abortion counseling could be improved by clarifying the process of fetal tissue handling and, when available, discussing options for fetal tissue donation. IMPLICATIONS: Informed pregnant individuals who have had an abortion appear to be supportive of fetal tissue research and their views can differ from the concerns of ethicists, politicians, and scientists. The perspective of the individuals donating fetal tissue should be included in future discussions of fetal tissue research.

Intranasal fentanyl for first-trimester uterine aspiration pain: A randomized controlled trial.

OBJECTIVE: To evaluate whether administration of intranasal fentanyl reduces reported pain during first-trimester uterine aspiration. STUDY DESIGN: We conducted a multicenter, randomized, double-blind, placebo-controlled trial of patients with pregnancies less than or equal to 14 weeks gestation seeking uterine aspiration for induced abortion, early pregnancy loss, or failed medication abortion. We randomized participants 1:1 to either intranasal fentanyl 100 mcg or intranasal placebo. All participants received ibuprofen and a standardized paracervical block. The primary outcome was pain indicated at the time of uterine aspiration on a 100 mm visual analog scale (VAS). We designed the study to detect a 15 mm difference in mean pain scores, which required 53 people in each arm for a total of 106 participants. Secondary outcomes included postprocedure pain and patient satisfaction with pain control. RESULTS: From March 2017 through June 2018, we screened 355 people for eligibility and enrolled 107 participants. Those who received intranasal fentanyl reported similar uterine aspiration pain to participants who received placebo (58.4 ± 28.0 fentanyl vs 58.6 ± 24.5 placebo, p = 0.97). Participants who received intranasal fentanyl also reported similar postprocedure pain scores compared to participants who received placebo (19.1 ± 19.4 fentanyl vs 17.2 ± 19 placebo, p = 0.63), and were equally satisfied with procedure pain control (66.8 ± 31.2 fentanyl vs 63.3 ± 29.2 placebo, p = 0.57). CONCLUSION: Intranasal fentanyl did not decrease reported pain with first-trimester uterine aspiration, nor did it decrease postprocedure pain compared to placebo. As an adjunct to ibuprofen and paracervical block, intranasal fentanyl did not improve patient satisfaction with pain control. IMPLICATIONS: Intranasal fentanyl does not reduce reported pain with first-trimester uterine aspiration, however abortion-seeking patients are amenable to receiving intranasal medications for pain management.

The experience of pain in real-time during medication abortion.

OBJECTIVE: We aimed to characterize the current pain experience of patients completing an evidence-based mifepristone-misoprostol medication abortion regimen using real-time pain scores. STUDY DESIGN: We collected real-time data on pain experienced by 54 women undergoing medication abortion using an evidence-based regimen of 200 mg mifepristone and 800 mcg buccal misoprostol. These women were enrolled in the placebo arm of a study on the effect of pregabalin for pain during medication abortion. All participants were dispensed ibuprofen and oxycodone/acetaminophen for analgesia. We assessed maximum pain experienced by participants on an 11-point numerical rating scale (NRS), duration of pain, and analgesic usage. Data was collected through electronic surveys sent via text message link at 6 specified points over 72 hours. RESULTS: Of the 54 women randomized to the placebo group, 2 were lost to follow-up. Participants experienced a mean maximum pain score of 5.5 ± 2.2. The mean time to maximum pain was 3.7 ± 2.4 hours after misoprostol. By hour 12 after misoprostol, 60.8% of participants reported no pain, which increased to 76.9% at 24 hours and 82.0% at 72 hours. Participants reported median ibuprofen usage of 2 800 mg tablets and median oxycodone/acetaminophen usage of one-half of a 5/325mg tablet. Approximately 12.0% of participants reported taking zero ibuprofen tablets, and 50.0% reported no opioid usage during the study period. CONCLUSIONS: Our real-time data collection demonstrated lower mean maximum experienced pain scores and shorter duration of pain than previously reported for medication abortion. Analgesic use was lower than previously described. IMPLICATIONS: This updated characterization of pain experienced during an evidence-based medication abortion regimen may allow for better pain-related counseling, tailoring of opioid prescription practices, and improvement in patient satisfaction.

Over-the-counter access to levonorgestrel emergency contraception in South Texas: Does Over-the-counter mean ready to buy?

OBJECTIVE: To determine the percentage of pharmacies in Hidalgo County, Texas, with unrestricted over-the-counter access to levonorgestrel emergency contraceptive pills (ECPs). Unrestricted over-the-counter access means product is available directly to consumer on store shelf, in-stock the day of data collection, and with no security barriers present (such as locked cabinet or individual locked product container), and to compare this access to that of other reproductive health items. STUDY DESIGN: We conducted in-person secret shopper surveys from October 2018 to March 2019, recording in-stock over-the-counter availability of levonorgestrel ECPs, security barriers, and price. We collected the same information for condom multipacks, ovulation prediction test kits, and pregnancy tests. RESULTS: Out of the 76 pharmacies surveyed, 31 (40.8%) sold levonorgestrel ECPs over-the-counter, 23 (30.3%) had product in-stock over-the-counter and two (2.6%) had unrestricted over-the-counter access. Other reproductive health items such as condom multipacks, ovulation prediction test kits and pregnancy tests had unrestricted over-the-counter access in at least 33 (43.4%, p < 0.01) pharmacies. Of the chain pharmacies, 30 (73.2%) sold levonorgestrel ECPs over-the-counter with and without security barriers, while only one (2.9%) of the 35 independent pharmacies sold levonorgestrel ECPs over-the-counter with security barriers (p < 0.001). CONCLUSIONS: While previous research has noted high prevalence of levonorgestrel ECP availability in pharmacies, potential purchasers of over-the-counter levonorgestrel ECPs encounter access barriers not associated with other reproductive health products. These additional access barriers to levonorgestrel ECPs may increase consumer discomfort, decrease privacy, and delay access. IMPLICATIONS: Advocacy efforts may be needed to promote unrestricted access to over-the-counter emergency contraceptives on par with other reproductive health items.

Over-The-Counter Availability of Levonorgestrel Emergency Contraception in Pharmacies on Oahu.

Since the United States Food and Drug Administration's approval of over-the-counter levonorgestrel emergency contraception, access to this time-sensitive medication has improved. However, multiple barriers, including the cost of the medication and pharmacy availability, still exist. The objective of this study was to determine the over-the-counter availability of levonorgestrel emergency contraception in pharmacies on Oahu, Hawaii. We conducted a cross-sectional population-based study using in-person simulated patient encounters at all pharmacies on Oahu. Out of 109 chain pharmacies and 13 independent pharmacies, 102 (84%) pharmacies had levonorgestrel emergency contraception available over the counter. Of pharmacies in which it was available, 12.7% required an employee to unlock the medication, 37.3% required the medication to be unlocked at the register, 29.4% were packaged in a large plastic box, and 3.9% were packaged in a blister pack. Levonorgestrel emergency contraception is widely available as an over-the-counter medication in pharmacies on Oahu, yet there are packaging and display practices that make it less accessible. Many of these practices could be improved with pharmacy education or changes in store policies. Systems-based interventions are needed to improve the access to levonorgestrel emergency contraception as an over-the-counter medication.

Updating fetal foot length to gestational age references: a chart review of abortion cases from 2012 to 2014.

OBJECTIVES: We sought to develop an updated fetal foot length-to-gestational week reference range from patient-reported last menstrual period (LMP), ultrasound, and best-estimate for gestational age based on American College of Obstetricians and Gynecologists' (ACOG) pregnancy dating guidelines. Subsequently, we aimed to determine the impact, if any, of race/ethnicity on our findings and compare our measurements to commonly referenced ranges. METHODS: We performed a chart review of 610 dilation and evacuation records with gestational ages 14 weeks 0 days to 21 weeks 6 days from October 2012 to December 2014 in Honolulu, Hawaii. We analyzed records containing pathology-measured fetal foot length and three gestational age estimation methods using ANOVA tests, determined if race/ethnicity affected fetal foot length, and compared our measurements to previously published studies. RESULTS: Linear regression analysis demonstrated that ultrasound-derived gestational age dating provided the best-fit regression formula with an R-squared and adjusted R-squared value of 0.92. Patient body mass index (p=.15), parity (p=.15), and race (p=.99) did not affect the equation. Mean fetal foot length per gestational age differed from historically referenced ranges by 0.36-3.92 mm in either direction. CONCLUSIONS: Our population's fetal foot length per gestational age differed from ranges typically referenced by pathologists following abortion at all gestational ages, using all three methods of fetal gestational age estimation. As gestational age increased, the variability of fetal foot length measurements per gestational week increased. If post-abortion fetal foot length measurements are obtained, it is important to use an updated reference range. IMPLICATIONS: Reference ranges frequently used by pathologists to assess fetal foot length following abortion may be outdated, limiting their utility. If facilities routinely obtain these measurements to estimate gestational age, it is important to use an updated reference range.

Text message link to online survey: A new highly effective method of longitudinal data collection.

OBJECTIVES: To evaluate response rate to a text message link for an online survey as a method of data collection over the course of a medication abortion. STUDY DESIGN: This is a secondary analysis of a randomized, double-blind, placebo-controlled trial of 110 women initiating a medication abortion up to 70 days gestation. We sent a text message containing a link to an online survey collecting pain scores, analgesic use, and adverse effects at six time points over 72 h from time of misoprostol administration (0-, 2-, 6-, 12-, 24-, and 72-hours). Our primary outcome was the proportion of all text messages sent for which an online survey response was received. Secondary outcomes included the proportion of complete responses (all six surveys), responses received more than two hours after text prompt (defined as late), and differences in response rate by time of day. RESULTS: From June 2015 to October 2016, we screened 241 women, and 110 were randomized. We excluded three (1.2%) due to lack of a cellular phone with text capability, and three (2.7%) were lost to follow-up after enrollment. We received a response to 95.9% (633/660) of the delivered surveys, and 93.6% (103/110) of participants completed all six surveys. Over three-quarters of all responses were received within two hours of the requested time. Surveys sent before 08:00 were more likely to be returned late. CONCLUSIONS: In this population of women seeking medication abortion, text message link to online survey response appears to be an effective mode of data collection. IMPLICATIONS: Text message prompts for an online survey may optimize longitudinal real-time data collection response rates of sensitive data.

Advanced Prescription of Emergency Contraceptive Pills Among Adolescents and Young Adults.

OBJECTIVE: To examine healthcare providers' adherence to professional recommendations for advanced prescription of emergency contraceptive pills (ECPs). METHODS: We conducted a retrospective chart review of 432 visits by 282 unique nonpregnant women 14 to 25 years of age seen at an obstetrics and gynecology teaching clinic to determine the percentage of visits during which advanced prescriptions of ECPs were provided when indicated. A logistic regression model, which accounted for nonindependent observations through generalized estimating equations, was used to identify factors associated with the provision of ECP advanced prescriptions. RESULTS: Approximately one-fifth of eligible visits (19.9%) and eligible patients (19.1%) had documentation of an ECP advanced prescription when indicated. Healthcare providers in this clinical setting were more likely to prescribe ECPs to adolescents and women whose primary contraceptive methods were associated with higher failure rates in typical use, such as condoms. Compared with women aged 20 to 25 years, the adjusted odds ratio of receiving an advanced prescription for ECPs was 5.94 (95% confidence interval [CI] 2.85-12.41) for adolescents. Compared with users of depot medroxyprogesterone acetate, the adjusted odds ratio was 4.25 (95% CI 1.62-11.15) for condom users, and 3.90 (95% CI 1.54-9.86) for users of other short-term hormonal contraceptives. CONCLUSIONS: Despite clear professional recommendations for ECP advanced prescriptions for all women at risk for unintended pregnancy, a substantial gap exists between this standard of care and routine clinical service provision in an obstetrics and gynecology teaching clinic.

Effects of Prophylactic Oxytocin on Bleeding Outcomes in Women Undergoing Dilation and Evacuation: A Randomized Controlled Trial.

OBJECTIVE: To estimate whether routine use of intravenous oxytocin decreases the frequency of interventions to control excess blood loss during dilation and evacuation (D&E). METHODS: In this multisite, randomized, double-blind, placebo-controlled trial, women undergoing D&E at 18-24 weeks of gestation received 30 units of oxytocin in 500 mL of intravenous fluid or 500 mL of intravenous fluid alone initiated on speculum placement. The primary outcome was the frequency of interventions to control excess bleeding. A sample size of 75 patients per group was needed to detect a 15% decrease in intervention from 20% to 5% with 80% power and two-sided alpha 0.05. Secondary outcomes included measured blood loss, complications, procedure duration, postoperative pain, and patient satisfaction. RESULTS: From November 2014 to February 2018, we screened 337 women and randomized 160 to receive prophylactic oxytocin (n=82) or placebo (n=78). Demographic characteristics were similar between groups. The frequency of interventions for bleeding, our primary outcome, was 7.3% in the oxytocin group vs 16.7% in the placebo group, difference of 9.4% (95% CI -21.0% to 1.9%). Interventions primarily included uterine massage and uterotonic administration. Among our secondary outcomes, median measured blood loss was lower in the oxytocin group at 152 (interquartile range 98-235) mL vs 317 (interquartile range 168-464) mL (95% CI 71.6-181.5). Frequency of hemorrhage, defined as blood loss of 500 mL or more and 1,000 mL or more, was lower in the oxytocin group at 3.7% vs 21.8%, difference of 18% (95% CI -29 to -6.9%) and 1.2% vs 10.3%, difference of 9.0% (95% CI -17 to -0.7%), respectively. Procedures were shorter in the oxytocin group at a median of 11.0 (interquartile range 8.0-14.0) vs 13.5 (interquartile range 10.0-19.0) minutes in the placebo group (95% CI 1.0-4.0). We found no differences in the frequency of nonhemorrhage complications, pain scores, or satisfaction scores between groups. CONCLUSION: Prophylactic use of oxytocin during D&E at 18-24 weeks of gestation did not decrease the frequency of interventions to control bleeding. However, oxytocin did decrease blood loss and frequency of hemorrhage. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT02083809.

Promotion of Long-Acting Reversible Contraception Among Adolescents and Young Adults.

INTRODUCTION: Intrauterine devices and contraceptive implants are recommended as first-line contraceptives by health care professional societies. However, uptake among US women lags substantially behind other developed countries. Little information is available on the extent to which clinicians document discussion about long-acting reversible contraception (LARC) in this patient population. We sought to determine the frequency with which clinicians document LARC discussion with eligible women aged 14 to 25 years in a training clinic and evaluate factors associated with LARC discussion and uptake. METHODS: We conducted a retrospective chart review of all visits of nonpregnant women aged 14 to 25 years seen at an obstetrics and gynecology resident physician clinic during a calendar year. A logistic regression model was used to assess demographic factors associated with LARC education and uptake. RESULTS: Among 450 visits by eligible patients, LARC discussion was documented during 47.8% (215/450) of visits. Among visits with documentation of LARC counseling, 45.6% (98/215) had documentation of a LARC placement plan. Among patients who decided to initiate LARC, 40.8% (40/98) had a device placed at the same visit. LARC placement was documented during 8.9% (40/450) of visits. Clinicians documented LARC counseling for women aged 14 to 19 years more frequently than for women aged 20 to 25 years. Compared with women who did not use any method of contraception, clinicians documented LARC counseling less frequently for women who used short-term hormonal contraception. DISCUSSION: Clinicians in a training clinic did not document LARC counseling for more than half of eligible patients. Every clinical visit is an opportunity to assess risk of unintended pregnancy and ensure that contraceptive needs are addressed.

Prophylactic Pregabalin to Decrease Pain During Medication Abortion: A Randomized Controlled Trial.

OBJECTIVE: To evaluate whether prophylactic pregabalin reduces pain experienced with medication abortion. METHODS: We conducted a randomized, double-blind, placebo-controlled trial of women initiating medication abortion with mifepristone and buccal misoprostol up to 70 days of gestation. Participants were randomized to 300 mg oral pregabalin or a placebo immediately before misoprostol. The primary outcome was maximum pain on an 11-point numerical rating scale, reported using real-time electronic surveys over 72 hours. Secondary outcomes included pain at each time point, ibuprofen and narcotic use, side effects, and satisfaction. We estimated that 110 women would be required to have 80% power to detect a difference in pain of 1.3 points. RESULTS: Between June 2015 and October 2016, 241 women were screened and 110 were randomized (56 pregabalin, 54 placebo). Three were lost to follow-up. The primary outcome of mean maximum pain in the pregabalin group was 5.0±2.6 vs 5.5±2.2 in the placebo group (P=.32). Excluding medication taken before the study capsule, ibuprofen was used by 64% (35/55) of the pregabalin group vs 87% (45/52) placebo (P<.01). Narcotics were used by 29% (16/55) of the pregabalin group vs 50% (26/52) placebo (P<.03). More dizziness (P<.001), sleepiness (P<.04), and blurred vision (P<.05) occurred in the pregabalin group. Satisfaction scores for the analgesic regimen were higher in the pregabalin group (very satisfied: 47% vs 22%; P=.006). CONCLUSION: Compared with placebo, 300 mg pregabalin coadministered with misoprostol during medication abortion did not significantly decrease maximum pain scores. Women who received pregabalin were less likely to require any ibuprofen or narcotic and were more likely to report higher satisfaction with analgesia, despite an increase in dizziness, sleepiness, and blurred vision. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT02782169.

Patient choice of adjunctive nonpharmacologic pain management during first-trimester abortion: a randomized controlled trial.

OBJECTIVE: To determine if offering patients a choice of adjunctive nonpharmacologic pain management during first-trimester aspiration abortion results in lower pain scores when compared with standard care. STUDY DESIGN: We enrolled women receiving first-trimester aspiration abortion at the University of Hawaii. We randomized patients to standard care (control) or standard care plus a choice of nonpharmacologic pain management options (intervention). Standard care was ibuprofen 800 mg orally at least 30 min preprocedure, lidocaine paracervical block and anticipatory guidance from the provider. We measured pain on a 100-mm visual analog scale immediately postprocedure with adequate sample size to detect a 20-mm difference in pain scores. RESULTS: Seventy-four women participated in the trial and reported an overall mean pain score of 61.9±27.0. Participants in the control and intervention groups reported similar overall mean pain scores (control 60.6±28.8, intervention 63.3±28.5). We found procedure time, complications, provider-perceived case difficulty and patient satisfaction with pain management to be similar between groups. Providers underestimated participant pain compared to participants' own scores (mean physician estimate of participant pain: 46.3±18.5, mean participant pain score: 61.9±27.0, p<.01). Intervention group participants most frequently selected ambient music (59%) as the nonpharmacologic intervention. Forty-one percent (15/37) of participants in the intervention group chose more than one nonpharmacologic intervention. CONCLUSIONS: Participants in the control group reported similar pain scores to participants in the intervention group. Procedure time and difficulty were similar between the two groups. IMPLICATIONS: Incorporating patient choice into a nonpharmacologic pain management model did not result in lower pain scores. This approach did increase the patient's visit time. Abortion providers frequently use nonpharmacologic pain management in the United States, and these techniques did not negatively impact patient pain scores in our study.

Use of medications to decrease bleeding during surgical abortion: a survey of abortion providers' practices in the United States.

OBJECTIVE: Our objective was to document current practices of abortion providers on the use of medications to decrease bleeding during surgical abortion. STUDY DESIGN: We emailed surveys to 336 abortion providers through a professional listserv to elicit information on their use of medications to prevent and treat bleeding during first- and second-trimester surgical abortion. RESULTS: One hundred sixty-eight (50%) providers responded to our survey. The majority were obstetrician-gynecologists (83%) working in an academic practice (66%). Most completed a fellowship in family planning (87%) and currently perform abortions up to 22 or 24weeks of gestation (63%). Seventy-two percent routinely used prophylactic medications for bleeding. Providers who routinely used medications to prevent bleeding most commonly chose vasopressin (83%). Providers preferred methylergonovine as a treatment for excessive bleeding in the second trimester, followed by misoprostol. CONCLUSION: We found that most providers routinely use medications to prevent bleeding and use several different regimens to treat bleeding during abortion. IMPLICATIONS: We found that surgical abortion providers use a range of medications to prevent and treat hemorrhage at the time of surgical abortion. Scant evidence is available to guide abortion providers on the use of medications to decrease hemorrhage during surgical abortion. To provide evidence-based recommendations for the prevention and treatment of clinically significant bleeding, researchers should target the most commonly used interventions.

Immediate Versus Delayed Insertion of the Levonorgestrel Intrauterine Device in Postpartum Adolescents: A Randomized Pilot Study.

This pilot study assessed the feasibility of conducting a larger randomized controlled trial comparing the proportion of adolescents using a levonorgestrel intrauterine device (LNG IUD) at six months postpartum when it is inserted immediately after vaginal delivery (within 10 minutes after placental expulsion) compared to insertion four to six weeks postpartum. Pregnant adolescents (14 to 19 years) who desired a LNG IUD for postpartum contraception were randomized to insertion of the LNG IUD either within 10 minutes of delivery of the placenta or at 4-6 weeks postpartum. Study follow-up visits were conducted at 4-6 weeks postpartum, 10 weeks postpartum, and 6 months postpartum. From November 2013 to June 2015, eleven adolescents were randomized - six participants to the immediate postpartum LNG IUD insertion group, and five to the delayed insertion group. All six women in the immediate insertion group had successful immediate postpartum insertion; two of five women in the delayed insertion group had an IUD inserted. At six months postpartum, four of six women in the immediate insertion group had a LNG IUD in place; of the five women in the delayed group, three did not have a LNG IUD in place and two were pregnant. The study was discontinued after 19 months because of suboptimal enrollment. Though insertion of a LNG IUD immediately after delivery is an appropriate option for some adolescents, a larger prospective study comparing immediate to delayed LNG IUD insertion is unlikely to be feasible at our institution.

Recommendations for Contraception: Examining the Role of Patients' Age and Race.

The literature suggests that women of different races are more or less likely to use certain contraceptive methods and patient race can influence which contraceptive recommendations a provider makes. To explore whether health care providers treat individuals of different races differently, we conducted a preliminary investigation on whether medical students recommended different contraceptive methods for hypothetical patients presenting with the same clinical features who only varied by race. Third- and fourth-year medical students (n=103) at the University of Hawai'i completed an online survey. Students read case studies about a 23-year-old and 36-year-old patient and then made contraceptive recommendations. All students reviewed the same scenarios, with the exception of the patient's name which was randomly assigned to represent one of five racial/ethnic groups (White, Chinese, Filipina, Native Hawaiian, and Micronesian). Recommendations were analyzed using χ2 tests and bivariate logistic regressions. For the younger patient, students were most likely to recommend intrauterine devices (IUDs), followed by the contraceptive pill and Etonogestrel implant; recommendations did not differ by race/ethnicity (P = .91). For the older patient, students were most likely to recommend IUDs or sterilization, and Micronesian women were more likely to receive sterilization recommendations compared to White women (60% versus 27%, P = .04). In summary, contraceptive recommendations, specifically the frequency of recommending sterilization varied by race. Our findings add to the literature exploring the role of a patient's race/ethnicity on recommendations for contraception and highlights the need for more studies exploring the etiology of health care disparities.

Pharmacy access to Ulipristal acetate in major cities throughout the United States.

OBJECTIVE: Ulipristal acetate (UPA) is a prescription emergency contraceptive pill (ECP). Despite the potential for UPA to reduce the risk of unintended pregnancies, a recent study in Hawaii demonstrated less than 3% of pharmacies stocked UPA and less than 23% reported the ability to order it. The primary outcome of our study was to assess the availability of UPA in a sample of large cities nationwide. STUDY DESIGN: We conducted a telephone-based secret shopper study of 533 retail pharmacies sampled proportionally from 10 large cities in five geographic regions across the US. Callers represented themselves as uninsured 18-year-old women attempting to fill prescriptions for UPA between February and May 2016. Using a semi-structured questionnaire, callers inquired regarding availability and use of UPA. RESULTS: Less than 10% (33/344; 95% CI: 6.5-12.7%) of pharmacies indicated the ability to immediately fill a UPA prescription, while 72% (224/311; 95% CI: 65.0-77.0%) of pharmacies without immediate availability reported the ability to order UPA, with the median predicted wait time of 24 h (IQR: 21.5 to 26.0 h). CONCLUSION: Despite evidence for increased efficacy of UPA over levonorgestrel (LNG) ECPs, the availability of UPA in a sample of US major cities is extremely limited. Given that ECPs should be taken as soon as possible after unprotected sex, the long wait times when ordering UPA present an access barrier. Efforts to improve the availability of UPA are important to optimize the potential of ECPs to decrease unintended pregnancy following unprotected sex. IMPLICATIONS: Interventions are needed to address barriers to obtaining UPA from retail pharmacies nationwide.