Protocol versus practice: Deviations from guidelines in low-risk twin deliveries in the United States.

BACKGROUND: Medical guidelines recommend vaginal delivery for low-risk twin pregnancies because cesareans increase the probability of maternal morbidity and mortality. Yet, vaginal delivery rates for twins are considerably lower than for comparable singletons. One explanation for this disparity argues that greater risk associated with twins warrants increased surgical intervention. An alternative explanation is that twin deliveries are more likely to deviate from protocols that advise vaginal birth. METHODS: Using the 2017 Natality Detail File (N = 3,197,401), we measured alignment of vaginal birth and trial of labor (TOL) with the American College of Obstetricians and Gynecologists' guidelines for twin and singleton no-indicated-risk births. We calculated predicted probabilities for the population and by maternal race/ethnicity to assess whether low rates of vaginal births among twins are explained by associated risk factors, or by deviations from recommended delivery methods. RESULTS: Overall, 31.2% of twins were born vaginally compared with 79.4% of singletons. Controlling for indicated risks, the predicted probability of vaginal birth for twins was 0.49 and 0.85 for singletons. The predicted probability of TOL for twins was 0.18 and 0.47 for singletons. Maternal race/ethnicity was only weakly associated with mode of delivery. These findings indicate that no-indicated-risk twin pregnancies, across maternal racial/ethnic categories, have lower probabilities of vaginal birth and TOL than would be expected with widespread adherence to current guidelines. CONCLUSIONS: Given the life-threatening consequences that may result from unnecessary surgical procedures, our findings highlight the need for further research to illuminate medical and nonmedical mechanisms driving nonadherence to clinical guidelines for twin births.

The biomedicalization of pregnancy prevention, neoliberal feminism, and college women's experiences of the contraceptive paradox.

Research examining the "contraceptive paradox" has illuminated how contraception can be a source of empowerment for some and oppression for others. This study advances theorizing of the contraceptive paradox by illustrating how 45 young women experience contraception as both liberating and constraining due to a confluence of biomedicalization processes, gender inequality, and neoliberal feminism. Drawing on focus group data, we find that the biomedicalization of pregnancy prevention and neoliberal feminist discourse, in combination with experiences of social and economic privilege and gender inequality in fertility work, shape participants' interpretation of contraceptive technology as a key resource for individually liberating themselves from undesired pregnancy. At the same time, their experiences indicate prescription contraception plays an oppressive role in their lives. In addition to blaming themselves and their bodies for negative contraceptive side effects, participants take for granted that assuming sole responsibility for contraceptive use in their relationships with men is the price they must pay to feel free. The findings indicate that addressing a social problem using an individualized biomedical solution obscures the power that structural inequalities exert over pregnancy-capable people, including relatively privileged young women. As an expression of biopower, these dynamics prompted participants to emphasize distributive justice over social justice, foreclosing their engagement in collective action.

Comparing Current, Former, and Never Users of Natural Family Planning An Analysis of Demographic, Socioeconomic, and Attitudinal Variables.

This project examines how women who currently use natural family planning (NFP), those who formerly used NFP, and those who have never used NFP compare along demographic, socioeconomic, and attitudinal variables. Bivariate analyses of data from the National Survey of Family Growth 2006-2010 (N = 10,598 female respondents) suggest that current NFP users varied socioeconomically and demographically from former NFP users, but differences were more prominent between current NFP users and never NFP users. In many cases, there was little variation between former NFP users and never NFP users. Current NFP users were less likely to be black and more likely to be Hispanic or other race, married, Catholic or other religion, have a bachelor's degree, and earn higher income than the other two groups. Understanding how current NFP users differ from those who formerly used NFP and those who have never tried NFP provides important clues about which populations to target for promotional efforts.

Efficacy as safety: Dominant cultural assumptions and the assessment of contraceptive risk.

To reduce rates of unintended pregnancy, medical and public health associations endorse a contraceptive counseling model that ranks birth control methods by failure rate. This tiered model outlines all forms of birth control but recommends long-acting reversible contraceptives (LARC) to eliminate user error and increase continuation. Our critical discourse analysis of gynecology textbooks and medical recommendations examines how gendered and neoliberal ideas influence risk assessments underlying the tiered contraceptive counseling model. Specifically, we explore how embodied, lifestyle, and medical risks are constructed to prioritize contraceptive failure over adverse side effects and reproductive autonomy. We find that the tiered model's focus on contraceptive failure is justified by a discourse that speciously conflates distinct characteristics of pharmaceuticals: efficacy (ability to produce intended effect) and safety (lack of unintended adverse outcomes). Efficacy discourse, which filters all logic through the lens of intended effect, magnifies lifestyle and embodied risks over medical risks by constructing two biased risk assessments. The first risk assessment defines ovulation, menstruation, and pregnancy as hazardous (i.e., embodied risk); the second insinuates that cisgender women who do not engage in contraceptive self-management are burdensome to society (i.e., lifestyle risk). Combined, these assessments downplay side effects (i.e., medical risks), suggesting that LARC and other pharma-contraceptives are worth the risk to protect cisgender women from their fertile bodies and to guard society against unintended pregnancy. Through this process, ranking birth control methods by failure rates rather than by side effects or reproductive autonomy becomes logical as efficacy is equated with safety for cisgender women and society. Our analysis reveals how technoscientific solutions are promoted to address social problems, and how informed contraceptive choice is diminished when pharma-contraceptives are framed as the most logical option without cogent descriptions of their associated risks.

Constructing contentious and noncontentious facts: How gynecology textbooks create certainty around pharma-contraceptive safety.

Using critical discourse analysis, we examine how seven popular gynecology textbooks use sociolinguistic devices to describe the health effects of pharma-contraception (intrauterine and hormonal methods). Though previous studies have noted that textbooks generally use neutral language, we find that gynecology textbooks differentially deployed linguistic devices, framing pharma-contraceptive benefits as certain and risks as doubtful. These discursive strategies transform pharma-contraceptive safety into fact. We expand on Latour and Woolgar's concept of noncontentious facts by showing how some facts that are taken for granted by the medical community still require discursive fortification to counter potential negative accusations from outside the profession. We call these contentious facts. Our findings suggest that a pro-pharma orientation exists in gynecology textbooks, which may influence physicians' understanding of pharmaceutical safety. As such, these texts may affect medical practice by normalizing pharma-contraceptives without full considerations of their risks.