COVID-19 Vaccine Hesitancy in the Perinatal Period: A Survey Among Residents of Hawaii.

Introduction: This study describes the vaccination status among people in Hawaii who are attempting pregnancy, currently pregnant, recently delivered (<6 months), and/or breastfeeding and documents common concerns and information sources associated with vaccine decision making. Methods: We conducted a cross-sectional online survey between April and September 2022 throughout Hawaii. The anonymous surveys were disseminated through flyers and online links posted by physician offices and community partners throughout Hawaii. Results: Final analyses included 165 responses. Almost half of the respondents (n=75, 45%) were unvaccinated, 38% (n=62) were fully vaccinated, and 17% (n=28) were partially vaccinated. The most influential sources for vaccine decision making for vaccinated respondents were their healthcare providers (n=28, 45%) and official healthcare organizations (n=22, 36%), whereas unvaccinated respondents reported friends/family (n=28, 37%) and their healthcare providers (n=26, 35%) as their most influential sources. Top COVID-19 vaccine concerns for unvaccinated individuals were reactions to vaccine (n=78, 76%) and concerns for safety of the vaccine (n=75, 73%). Conclusions: Efforts should be made to increase and expand vaccine education about the benefits and safety of vaccines during pregnancy beyond the pregnant person to create more supportive social norms for COVID-19 vaccination in the perinatal period. Consistent and unequivocal support across medical specialties, including obstetrics, pediatrics, and family medicine, is also crucial for encouraging the uptake of the vaccine during pregnancy or when breastfeeding.

Patient Barriers to Discontinuing Long-Acting Reversible Contraception.

OBJECTIVES: To describe how frequently a national sample of patients with experience discontinuing or desiring discontinuation of long-acting reversible contraception (LARC) experienced barriers to discontinuation. METHODS: We conducted an online survey of individuals ages 18 to 50 in the United States who had previously used and discontinued or attempted to discontinue LARC. We recruited respondents using the Amazon platform MTurk. Respondents provided demographic information and answered questions regarding their experience discontinuing LARC, including reasons removal was deferred or denied. We analyzed frequency of types of barriers encountered and compared these by demographic factors. RESULTS: Of the 376 surveys analyzed, 99 (26%) described experiencing at least one barrier to removal. Barriers were disproportionately reported by those who had public health insurance, a history of abortion, and a history of birth compared to those who did not report barriers to removal. They also more frequently identified as Latinx, Asian, or Middle Eastern. Most barriers were provider-driven and potentially modifiable. CONCLUSIONS FOR PRACTICE: Barriers to LARC discontinuation are common and may be provider- or systems-driven. Providers should be mindful of biases in their counseling and practices to avoid contributing to these barriers.

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.

Oxytocin and Hypotension During Dilation and Evacuation Procedures at 18-24 Weeks Gestation.

Oxytocin is a neurohormone that is routinely administered to patients during dilation and evacuation procedures (D&E) to control bleeding despite minimal evidence in support of this common practice. In this study, the authors sought to evaluate patients with hypotension after receiving oxytocin during D&E procedures. The secondary data from a double-blind, randomized, placebo-controlled trial involving 112 patients who underwent a D&E at 18-24 weeks gestation and prophylactically received an intravenous bolus of either 30 units of oxytocin in 500 mL of normal saline or 500 mL of saline alone at the start of the procedure were analyzed. Anesthesia providers measured blood pressure before, at the time of, and after study medication administration in 5-minute increments until the end of the procedure. No differences in demographic characteristics or mean blood pressure between the 2 groups were observed. The proportion of hypotensive patients was not statistically different at 5 minutes following fluid bolus (oxytocin 25% versus placebo 13%, P=.09). The proportion of hypotensive patients was similar by 10 minutes (oxytocin 20% versus placebo 16%, P=.62). A sample size of 112 provided the ability to detect a 23% difference in the proportion of patients who experienced hypotension (2-sided 95% CI, power of 80%). These findings suggest that oxytocin may have a transient hypotensive effect.

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.

Changes to medication abortion clinical practices in response to the COVID-19 pandemic.

OBJECTIVES: To document medication abortion clinical practice changes adopted by providers in response to the COVID-19 pandemic. STUDY DESIGN: Longitudinal descriptive study, comprised of three online surveys conducted between April to December, 2020. We recruited sites from email lists of national abortion and family planning organizations. RESULTS: Seventy-four sites opted to participate. We analyzed 55/74 sites (74%) that provided medication abortion and completed all three surveys. The total number of abortion encounters reported by the sites remained consistent throughout the study period, though medication abortion encounters increased while first-trimester aspiration abortion encounters decreased. In response to the COVID-19 pandemic, sites reduced the number of in-person visits associated with medication abortion and confirmation of successful termination. In February 2020, considered prepandemic, 39/55 sites (71%) required 2 or more patient visits for a medication abortion. By April 2020, 19/55 sites (35%) reported reducing the total number of in-person visits associated with a medication abortion. As of October 2020, 37 sites indicated newly adopting a practice of offering medication abortion follow-up with no in-person visits. CONCLUSIONS: Sites quickly adopted protocols incorporating practices that are well-supported in the literature, including forgoing Rh-testing and pre-abortion ultrasound in some circumstances and relying on patient report of symptoms or home pregnancy tests to confirm successful completion of medication abortion. Importantly, these practices reduce face-to-face interactions and the opportunity for virus transmission. Sustaining these changes even after the public health crisis is over may increase patient access to abortion, and these impacts should be evaluated in future research. IMPLICATIONS STATEMENT: Medication abortion serves a critical function in maintaining access to abortion when there are limitations to in-person clinic visits. Sites throughout the country successfully and quickly adopted protocols that reduced visits associated with the abortion, reducing in-person screenings, relying on telehealth, and implementing remote follow-up.

Meeting Women's Requests for Intrauterine Device and Contraceptive Implant Discontinuation: An Exploratory Survey of Physicians.

Long acting reversible contraceptives (LARC), including intrauterine devices (IUDs) and contraceptive implants, can support an individual in meeting their reproductive goals by allowing them to prevent pregnancy effectively. These devices can also limit an individual's control over reproduction because they generally require an in-person visit to a health care provider for removal. Returning for another visit may be logistically challenging for many individuals who may need to arrange for transportation, childcare, or take time off from work. Effectively negotiating with a provider to request removal may be additionally challenging for medically underserved and disenfranchised people who may not feel empowered to do so. The objective of this study was to assess providers' willingness to honor patients' requests for IUD and contraceptive implant removal on the day of the request. A survey was conducted in which clinicians were presented with scenarios of women requesting IUD or implant removal. Clinicians were asked what they were most likely to do. A total of 105 clinicians were surveyed. The responses of 60 clinicians who inserted IUDs and 57 who provided the contraceptive implant were included in the analysis. When asked about same-day removal of an IUD or implant from a dissatisfied patient who requested removal, 40% stated they would remove the implant, and 57% stated they would remove the IUD on the day of the request. Findings from this study suggest many clinicians would be unwilling or unable to accommodate a patient's request for device removal at the time of their visit. This delay or refusal represents a significant barrier for patients and has implications for reproductive autonomy that should be further explored.

Insights in Public Health: Insurance Coverage for Long-Acting Reversible Contraception Placed in Office: A Buy and Bill Demonstration Project in Hawai'i.

Access to the full range of contraceptive options for all people is critical in allowing individuals to make decisions that are consistent with their reproductive goals and values, which, in turn, enables them to achieve educational, social, and economic goals. In 2010, the Patient Protection and Affordable Care Act mandated that health plans must cover contraceptive supplies and services, including drugs and devices approved by the US Food and Drug Administration without any out-of-pocket costs to patients. This federal mandate was similar to a law passed by the Hawai'i state legislature in 1999. Despite the Affordable Care Act, access barriers continue to prevent people from obtaining their preferred methods upon request. Same day access to long-acting reversible contraceptive (LARC) devices is a particular challenge in many clinical settings due to the high upfront cost of the device for providers. This Insights article describes the context of this issue in Hawai'i and information about a pilot test of a "buy and bill" program for LARC devices in an outpatient obstetrics and gynecology practice in Honolulu, Hawai'i. Ultimately, the majority of LARC devices were paid for fully by insurance, resulting in increased access to same day insertion with limited financial risk for the clinic.

Survival Analysis of Patient Contraceptive Choice Method at Time of Abortion - Honolulu, Hawai'i, May 2010-December 2016.

The relationship between contraceptive method choice at the time of abortion and risk for subsequent abortions is not well understood. This article uses an existing data set from the University of Hawai'i Women's Options Center between May 2010 and December 2016 to examine if such a relationship exists. A multivariate Cox proportional hazards regression survival analysis was used to evaluate contraceptive method prescribed or provided at index abortion encounters and likelihood of additional abortions. Patients who received a prescription of oral contraceptive pills, patches or rings at their index abortion were 61% more likely to have an additional abortion than those who had no contraceptive method recorded (hazard ratio [HR], 1.61; 95% confidence interval [CI], 1.14-2.28). Patients who received a long-acting reversible contraceptive method at their index abortion were 59% less likely to have an additional abortion when compared with a patient receiving no method (HR, 0.41; 95% CI, 0.20-0.86). The findings show that patients who were prescribed oral contraceptives pills, patches, or rings were more likely than patients who had no contraceptive method prescribed or provided to have more than one abortion during the data collection period. Contraceptive method choice at time of abortion is complex and providers should be thorough in their counseling about failure rates, while also remaining vigilant in supporting patient autonomy and avoiding coercive or stigmatizing language.

"The Difference between Plan b and ella®? They're Basically the Same Thing": Results from a Mystery Client Study.

Pharmacy staff can serve an important role educating patients about emergency contraceptive pills (ECP), particularly ulipristal acetate (UPA), which requires a prescription. We conducted a secondary analysis of a previously completed mystery client study, assessing accuracy of information provided by pharmacy staffers to patients inquiring by telephone about filling a prescription for UPA. From the period December 2013 to July 2014, researchers used a mystery client methodology, contacting 198 retail pharmacies in Hawai'i. Researchers posed as patients or providers attempting to fill a prescription for UPA. During the course of the call, they asked about differences between UPA and levonorgestrel ECPs. Nearly half of all pharmacy staffers were unfamiliar with UPA. The majority of responses describing differences between the medications were incorrect or misleading, such as responses implying that UPA is an abortifacient. Lack of familiarity and incorrect information provided by pharmacy staffers may act as additional barriers in patient access to UPA. Health practitioners prescribing UPA should ensure patients receive evidence-based counseling at the time of prescription, while efforts should also be made to improve pharmacy staff familiarity with emergency contraceptive options.

Impact of Insurance Coverage for Abortion in Hawai'i on Gestational Age at Presentation and Type of Abortion, 2010-2013.

Insurance coverage for abortion varies between states, and in Hawai'i most private insurance companies and state Medicaid provide coverage for abortion. Very few patients pay out-of-pocket for an abortion. Hawai'i presents a unique opportunity to describe the sociodemographic differences between women seeking an abortion based on type of insurance coverage or who self-pay, and how this coverage impacts their care. Examined here were the differences in gestational age at time of presentation for abortion and type of abortion (medical, in-office procedure, or hospital facility procedure) chosen by 1803 patients presenting to a major abortion provider in Hawai'i from 2010 to 2013 based on payment method: private insurance, state Medicaid, and self-pay. Self-pay patients were demographically similar to those using private insurance with respect to age, race, and gestational age at time of presentation. Medicaid patients were distinct. They presented for care at a gestational age 13.3 days later than private insurance or self-pay patients even when controlling for age, race, prior parity, and prior abortion. Overall, 45.3% of Medicaid patients presented at greater than 14 weeks. Types of abortion differed between the insurance category groups, however these differences were no longer significant when stratified by gestational age. State Medicaid patients present for abortion care almost 2 weeks later than those with private insurance or who pay out of pocket, increasing personal and healthcare system costs associated with the procedure. The factors that contribute to this difference should be elucidated as they have important public health implications regarding timely access to care.

Dual-Method Contraception Among Adolescents and Young People: Are Long-Acting Reversible Contraception Users Different? A Qualitative Study.

STUDY OBJECTIVE: The purpose of this study was to understand the factors and influences that affect dual-method contraception in adolescent and young adult women using long-acting reversible contraception (LARC) and whether these are unique to LARC users. DESIGN: Qualitative semistructured interview study. SETTING AND PARTICIPANTS: Adolescents and young women aged 14-24 years using LARC methods, adolescents and young women aged 14-24 years using short-acting reversible contraception (SARC), and men aged 14-30 years. INTERVENTIONS: Interviews were conducted until thematic saturation was reached. MAIN OUTCOME MEASURES: The team used a grounded theory approach to identify common themes relating to dual-method contraception. RESULTS: Interviews were conducted with 20 LARC users, 26 SARC users, and 13 men. There were no differences in dual-method contraception use between LARC users and SARC users. Most participants used condoms primarily for pregnancy prevention rather than sexually transmitted infection (STI) prevention. Relationship context played an important role in dual-method contraception among all 3 groups; participants were less likely to use condoms in a long-term or monogamous relationship than with new or casual partners. Most participants perceived themselves to be at low risk for STI acquisition, although even those who identified themselves to be at risk did not consistently use condoms. Immediate availability of condoms was a determinant of condom use in all 3 groups, whereas knowledge, access, and negotiation of condom use were not. CONCLUSION: LARC users are similar to SARC users in their decision-making about condom use. Relationship factors and STI risk assessment are important components to be included in contraceptive counseling.

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.

Understanding the Family Planning Needs of Female Participants in a Syringe Exchange Program: A Needs Assessment and Pilot Project.

OBJECTIVES: To describe the reproductive health needs of women who inject drugs (WWID) and are participants in a syringe exchange program (SEP) in Hawaii. Our secondary objective was to develop and pilot services in response to those needs. METHODS: We conducted a reproductive health needs-assessment of women participating in the SEP. We also documented the perspectives and recommendations of key informants who work closely with women in this program. This needs-assessment informed a pilot contraceptive project at the SEP. RESULTS: We received surveys from 50 syringe exchange participants and hosted 1 focus group with 6 participants. We completed 8 key informant interviews. The majority of survey respondents indicated that they did not want to become pregnant in the next year, but most were not using a reliable method of contraception. Additionally, for most respondents, prevention of pregnancy was a lower priority than other health and wellness needs. Focus group participants and key informants emphasized the importance of developing a network of accessible providers to address reproductive health needs, and also the importance of using the principles of trauma-informed care when developing a service. We developed a pilot program to offer contraceptive injections at the syringe exchange program. In the first 6 months of offering the service, 1 participant elected to use the injection. CONCLUSIONS: WWID participating in this SEP may not prioritize their family planning needs when other health and safety needs are unmet. A pilot program to offer contraceptive injections at SEP had almost zero uptake.

TelAbortion: evaluation of a direct to patient telemedicine abortion service in the United States.

OBJECTIVES: To evaluate the safety, feasibility, and acceptability of a direct-to-patient telemedicine service that enabled people to obtain medical abortion without visiting an abortion provider in person. STUDY DESIGN: We offered the service in five states. Each participant had a videoconference with a study clinician and had pre-treatment laboratory tests and ultrasound at facilities of her choice. If the participant was eligible for medical abortion, the clinician sent a package containing mifepristone, misoprostol, and instructions to her by mail. After taking the medications, the participant obtained follow-up tests and had a follow-up consultation with the clinician by telephone or videoconference to evaluate abortion completeness. The analysis was descriptive. RESULTS: Over 32 months, we conducted 433 study screenings and shipped 248 packages. The median interval between screening and mailing was 7 days (91st percentile 17 days), and no participant took the mifepristone at ≫71 days of gestation. We ascertained abortion outcomes of 190/248 package recipients (77%): 177/190 (93%) had complete abortion without a procedure. Of the 217/248 package recipients who provided meaningful follow-up data (88%), one was hospitalized for postoperative seizure and another for excessive bleeding, and 27 had other unscheduled clinical encounters, 12 of which resulted in no treatment. A total of 159/248 participants who received packages (64%) completed satisfaction questionnaires at study exit; all were satisfied with the service. CONCLUSIONS: This direct-to-patient telemedicine abortion service was safe, effective, efficient, and satisfactory. The model has the potential to increase abortion access by enhancing the reach of providers and by offering people a new option for obtaining care conveniently and privately. IMPLICATIONS: Provision of medical abortion by direct-to-patient telemedicine and mail has the potential to increase abortion access by increasing the reach of providers and by offering people the option of obtaining abortion care without an in-person visit to an abortion provider.

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.