Study protocol: a mixed-methods study of the implementation of doula care to address racial health equity in six state Medicaid programs.

BACKGROUND: Racial inequities in severe maternal morbidity (SMM) and mortality constitute a public health crisis in the United States. Doula care, defined as care from birth workers who provide culturally appropriate, non-clinical support during pregnancy and postpartum, has been proposed as an intervention to help disrupt obstetric racism as a driver of adverse pregnancy outcomes in Black and other birthing persons of colour. Many state Medicaid programs are implementing doula programs to address the continued increase in SMM and mortality. Medicaid programs are poised to play a major role in addressing the needs of these populations with the goal of closing the racial gaps in SMM and mortality. This study will investigate the most effective ways that Medicaid programs can implement doula care to improve racial health equity. METHODS: We describe the protocol for a mixed-methods study to understand how variation in implementation of doula programs in Medicaid may affect racial equity in pregnancy and postpartum health. Primary study outcomes include SMM, person-reported measures of respectful obstetric care, and receipt of evidence-based care for chronic conditions that are the primary causes of postpartum mortality (cardiovascular, mental health, and substance use conditions). Our research team includes doulas, university-based investigators, and Medicaid participants from six sites (Kentucky, Maryland, Michigan, Pennsylvania, South Carolina and Virginia) in the Medicaid Outcomes Distributed Research Network (MODRN). Study data will include policy analysis of doula program implementation, longitudinal data from a cohort of doulas, cross-sectional data from Medicaid beneficiaries, and Medicaid healthcare administrative data. Qualitative analysis will examine doula and beneficiary experiences with healthcare systems and Medicaid policies. Quantitative analyses (stratified by race groups) will use matching techniques to estimate the impact of using doula care on postpartum health outcomes, and will use time-series analyses to estimate the average treatment effect of doula programs on population postpartum health outcomes. DISCUSSION: Findings will facilitate learning opportunities among Medicaid programs, doulas and Medicaid beneficiaries. Ultimately, we seek to understand the implementation and integration of doula care programs into Medicaid and how these processes may affect racial health equity. Study registration The study is registered with the Open Science Foundation ( https://doi.org/10.17605/OSF.IO/NXZUF ).

Knowing your team in the intensive care unit: an ethnographic study on familiarity.

Effective interprofessional team function is integral to high-quality care in the intensive care unit (ICU). However, little is known about how familiarity develops among teams, which may be an important antecedent to effective team function and quality care. To examine team familiarity and how it impacts ICU team function and care, we conducted an ethnographic study in four ICUs (two medical ICUs, one mixed medical-surgical ICU, and one surgical ICU) in two community hospitals and one academic medical center. We conducted 57.5 h of observation, 26 shadowing experiences, and 26 interviews across the four ICUs sequentially. We used thematic analysis to examine familiarity among the team. We found that ICU team members become familiar with their team through interpersonal, relational interactions, which involved communication, time working together, social interactions, trust, and respect. Our findings underscore the relational aspect of effective teams and demonstrate that time working together, social interactions, communication, developing trust, and respect are pathways to familiarity and optimal team function. Leveraging unique and creative ways to enhance the relational aspects of ICU teams could be an area for future research and lead to improved ICU outcomes.

Maternal health equity in Georgia: a Delphi consensus approach to definition and research priorities.

BACKGROUND: Pregnancy-related mortality in the United States is the greatest among all high-income countries, and Georgia has one of the highest maternal mortality rates-almost twice the national rate. Furthermore, inequities exist in rates of pregnancy-related deaths. In Georgia, non-Hispanic Black women are nearly 3 times more likely to die from pregnancy-related complications than non-Hispanic White women. Unlike health equity, a clear definition of maternal health equity is lacking, overall and in Georgia specifically, but is needed to reach consensus and align stakeholders for action. Therefore, we used a modified Delphi method to define maternal health equity in Georgia and to determine research priorities based on gaps in understanding of maternal health in Georgia. METHODS: Thirteen expert members of the Georgia Maternal Health Research for Action Steering Committee (GMHRA-SC) participated in an iterative, consensus-driven, modified Delphi study comprised of 3 rounds of anonymous surveys. In round 1 (web-based survey), experts generated open-ended concepts of maternal health equity and listed research priorities. In rounds 2 (web-based meeting) and 3 (web-based survey), the definition and research priorities suggested during round 1 were categorized into concepts for ranking based on relevance, importance, and feasibility. Final concepts were subjected to a conventional content analysis to identify general themes. RESULTS: The consensus definition of maternal health equity created after undergoing the Delphi method is: maternal health equity is the ultimate goal and ongoing process of ensuring optimal perinatal experiences and outcomes for everyone as the result of practices and policies free of interpersonal or structural bias that tackle current and historical injustices, including social, structural, and political determinants of health impacting the perinatal period and life course. This definition highlights addressing the current and historical injustices manifested in the social determinants of health, and the structural and political structures that impact the perinatal experience. CONCLUSION: The maternal health equity definition and identified research priorities will guide the GMHRA-SC and the broader maternal health community for research, practice, and advocacy in Georgia.

Scoping of advanced clinical practitioner role implementation using national job advertisements: Document analysis.

AIM: The aim of this study is to profile the contemporary advanced clinical practitioner (ACP) role through standardized document sets. DESIGN: Documentary analysis of job descriptions (JDs), person specification and advertisements. DATA SOURCES: England based jobs advertised on NHS jobs website from 22 January to 21 April 2021. RESULTS: A toatal of 143 trainee and qualified ACP roles were identified. A wide range of sectors and specialities were represented from across all English regions. The most common roles were urgent care, emergency medicine and primary care. Most qualified roles were agenda for change band 8A, although this did vary across specialities. Many roles were restricted to a small number of professions, notably nursing, physiotherapy and paramedic. Inconsistent role titles were noted. A lack of understanding of regulation across different professions was noted. CONCLUSION: The ACP role has become an accepted across healthcare providers in England. Implementation remains varied across specialities and organizations. Eligibility criteria may relate to professional bias. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: ACP roles are expanding but this may be at the detriment to advanced nursing posts. Inconsistency in role eligibility suggests some professional bias exists. IMPACT: This was scoping of ACP roles across England using job advertisements. ACP roles are common across sectors and specialities but eligibility varies. The research will have impact on those looking to recruit to ACP roles as well as those refining JDs. REPORTING METHOD: No EQUATOR guideline exists for document analysis. PATIENT OR PUBLIC CONTRIBUTION: No Patient or Public Contribution. The research relates to organizational human resource information only.

Alcohol use and alcohol-related consequences based on gender and sexual orientation among college students.

BACKGROUND AND OBJECTIVES: Research has not yet investigated how the association between alcohol and alcohol-related consequences differs across cisgender heterosexual women (CHW), cisgender heterosexual men (CHM), and sexual and gender minority (SGM) college students. METHODS: Participants were N = 754 college students (34.5% CHW [n = 260]; 34.5% CHM [n = 260]; 31.0% SGM [n = 234]) between the ages 18 and 25 who completed a survey on sexual orientation, gender identity, alcohol use (i.e., average drinks per week), and alcohol-related consequences. RESULTS: Among individuals who reported alcohol use, CHM reported significantly more drinks per week compared to CHW and SGM. The logistic model of a zero-inflated negative binomial regression indicated that excess zeros in the alcohol-related consequences were more likely among (1) nondrinkers and (2) SGM compared to CHM. The count portion of the model indicated that, among drinkers, there was a positive association between drinks per week and alcohol-related consequences. Estimated alcohol-related consequences per drink were 1.90% higher among CHW than CHM and 2.76% higher among SGM than CHM. Exploratory analyses did not find significant differences in outcomes between cisgender female and male sexual minority students. DISCUSSION AND CONCLUSION: Findings suggest that although CHW and SGM students consume less alcohol than CHM, these students experience more alcohol-related consequences per drink. SCIENTIFIC SIGNIFICANCE: This study advances the field's knowledge of alcohol use patterns and consequences among SGM college students. There is a need for alcohol education programming that is tailored to the unique experiences, identities, and minority stressors of SGM college students.

Exploring the process of information sharing in an adult intensive care unit: an ethnographic study.

Information sharing, a component of patient and family engagement (PFE), is an important process that may contribute to intensive care unit (ICU) quality of care. Yet, virtually no studies explore how the process of information sharing unfolds in the ICU from the interprofessional team and family member perspectives. To better understand the process of information sharing, we conducted ethnographic fieldwork in a 20-bed medical ICU, focusing on behaviors and interactions of the interprofessional team and family members (May 2016 - October 2016). We completed 17.5 observation hours, 6 shadowing sessions, and 12 semi-structured interviews with 17 total participants. We used thematic content analysis and iterative inductive coding to identify three themes about the information sharing process: 1) family factors (health literacy and past experience with the ICU environment) influence information sharing; 2) clinicians strategies can support engagement in the process of information sharing (assessing families' need for information, understanding a families' hope, using rounds as an opportunity for information sharing); 3) the process of information sharing allows for trust building between families and the ICU team. Our findings suggest that information sharing is a crucial process that may serve as a catalyst for effective patient and family engagement in the ICU.

Abortion Trends in Georgia Following Enactment of the 22-Week Gestational Age Limit, 2007-2017.

Objectives. To measure trends before, during, and after implementation of Georgia House Bill 954, a limit on abortion at 22 or more weeks of gestation passed in 2012, in total abortions and abortions by gestational age and state residence.Methods. We analyzed aggregate year-level induced termination of pregnancy data from the Georgia Department of Public Health from 2007 to 2017. We used linear regression to describe annual trends in the number of abortions and χ2 analyses to describe changes in proportions of abortions by gestational age (< 20 weeks, 20-21 weeks, and > 21 weeks) across policy implementation periods (before, partial, and full implementation) for Georgia residents and nonresidents.Results. Although the total number of abortions and abortions at 21 weeks or less remained stable from 2007 to 2017, the number of abortions at more than 21 weeks declined (P = .02). The decline in number of abortions at more than 21 weeks was steeper for nonresidents (31/year; Β = -31.3; P = .02) compared with Georgia residents (14/year; Β = -13.9; P = .06).Conclusions. Findings suggest that implementation of Georgia's 22-week gestational age limit has effectively limited access to needed abortion services in Georgia and beyond. (Am J Public Health. Published online ahead of print May 21, 2020: e1-e5. doi:10.2105/AJPH.2020.305653).

South African abortion attitudes from 2007-2016: the roles of religiosity and attitudes toward sexuality and gender equality.

Abortion is legal in South Africa, but negative abortion attitudes remain common and are poorly understood. We used nationally representative South African Social Attitudes Survey data to analyze abortion attitudes in the case of fetal anomaly and in the case of poverty from 2007 to 2016 (n = 20,711; ages = 16+). We measured correlations between abortion attitudes and these important predictors: religiosity, attitudes about premarital sex, attitudes about preferential hiring and promotion of women, and attitudes toward family gender roles. Abortion acceptability for poverty increased over time (b = 0.05, p < .001), but not for fetal anomaly (b = -0.008, p = .284). Highly religious South Africans reported lower abortion acceptability in both cases (Odds Ratio (OR)anomaly = 0.85, p = .015; ORpoverty = 0.84, p = .02). Premarital sex acceptability strongly and positively predicted abortion acceptability (ORanomaly = 2.63, p < .001; ORpoverty = 2.46, p < .001). Attitudes about preferential hiring and promotion of women were not associated with abortion attitudes, but favorable attitudes about working mothers were positively associated with abortion acceptability for fetal anomaly ((ORanomaly = 1.09, p = .01; ORpoverty = 1.02, p = .641)). Results suggest negative abortion attitudes remain common in South Africa and are closely tied to religiosity, traditional ideologies about sexuality, and gender role expectations about motherhood.

Abortion attitudes among South Africans: findings from the 2013 social attitudes survey.

Abortion is legal in South Africa, but over half of abortions remain unsafe there. Evidence suggests women who are (Black) African, of lower socioeconomic status, living with HIV, or residents of Gauteng, KwaZulu-Natal, or Limpopo provinces are disproportionately vulnerable to morbidity or mortality from unsafe abortion. Negative attitudes toward abortion have been documented in purposively sampled studies, yet it remains unclear what attitudes exist nationally or whether they differ across sociodemographic groups, with implications for inequities in service accessibility and health. In the current study, we analysed nationally representative data from 2013 to estimate the prevalence of negative abortion attitudes in South Africa and to identify racial, socioeconomic and geographic differences. More respondents felt abortion was 'always wrong' in the case of family poverty (75.4%) as compared to foetal anomaly (55%), and over half of respondents felt abortion was 'always wrong' in both cases (52.5%). Using binary logistic regression models, we found significantly higher odds of negative abortion attitudes among non-Xhosa African and Coloured respondents (compared to Xhosa respondents), those with primary education or less, and residents of Gauteng and Limpopo (compared to Western Cape). We contextualise and discuss these findings using a human rights-based approach to health.

A Decision Aid to Support Tubal Sterilization Decision-Making Among Pregnant Women: The MyDecision/MiDecisión Randomized Clinical Trial.

Importance: Tubal sterilization is common, especially among individuals with low income. There is substantial misunderstanding about sterilization among those who have undergone the procedure, suggesting suboptimal decision-making about a method that permanently ends reproductive capacity. Objective: To test the efficacy of a web-based decision aid for improving tubal sterilization decision quality. Design, Setting, and Participants: This randomized clinical trial conducted between March 2020 and November 2023 included English- or Spanish-speaking pregnant cisgender women aged 21 to 45 years who had Medicaid insurance and were contemplating tubal sterilization after delivery. Participants were recruited from outpatient obstetric clinics in 3 US cities. Intervention: Participants were randomized 1:1 to usual care (control arm) or to usual care plus a web-based decision aid (MyDecision/MiDecisión) (intervention arm). The aid includes written, audio, and video information about tubal sterilization procedures; an interactive table comparing contraceptive options; values-clarifying exercises; knowledge checks; and a summary report. Main Outcomes and Measures: The co-primary outcomes were tubal sterilization knowledge and decisional conflict regarding the contraceptive decision. Knowledge was measured as the percentage of correct responses to 10 true-false items. Decisional conflict was measured using the low-literacy Decision Conflict Scale, with lower scores on a range from 0 to 100 indicating less conflict. Results: Among the 350 participants, mean (SD) age was 29.7 (5.1) years. Compared with the usual care group, participants randomized to the decision aid had significantly higher tubal sterilization knowledge (mean [SD] proportion of questions answered correctly, 76.5% [16.9%] vs 55.6% [22.6%]; P < .001) and lower decisional conflict scores (mean [SD], 12.7 [16.6] vs 18.7 [20.8] points; P = .002). The greatest knowledge differences between the 2 groups were for items about permanence, with more participants in the intervention arm answering correctly that tubal sterilization is not easily reversible (90.1% vs 39.3%; odds ratio [OR], 14.2 [95% CI, 7.9-25.4]; P < .001) and that the tubes do not spontaneously "come untied" (86.6% vs 33.7%; OR, 13.0 [95% CI, 7.6-22.4]; P < .001). Conclusions and Relevance: MyDecision/MiDecisión significantly improved tubal sterilization decision-making quality compared with usual care only. This scalable decision aid can be implemented into clinical practice to supplement practitioner counseling. These results are particularly important given the recent increase in demand for permanent contraception after the US Supreme Court decision overturning federal abortion protections. Trial Registration: ClinicalTrials.gov Identifier: NCT04097717.

My Health in My Hands: Improving Medication Abortion Knowledge and Closing Disparities with a Community-Led Media Intervention.

Purpose: Inaccurate beliefs about medication abortion (MA) are common. This study evaluated pilot data from a community-led media intervention designed to increase MA knowledge among Black and Latinx women in Georgia. Methods: Participants (N=855) viewed the intervention video and completed pre-post surveys. Data were analyzed using linear and logistic regression. Results: Knowledge scores significantly increased from 3.88/5.00 to 4.47/5.00. Participants who were Native American, Asian and Pacific Islander, multiracial, Black, <20 years old, and living in Georgia scored below the sample mean at baseline; however, nearly all disparities disappeared after intervention exposure. Conclusions: This intervention effectively increased MA knowledge and narrowed racial/ethnic, age-based, and geographic disparities.

"I can be pro-abortion and pro-birth": Opportunities and challenges for full spectrum care among doulas in Georgia.

Background: The work of full spectrum doulas (i.e., non-medically trained care workers offering support before, during, and after pregnancy including abortion)-is increasingly important as abortion access decreases across the U.S. Few studies have examined the work of community-based doulas in restrictive abortion settings or how they might further incorporate full spectrum care. As part of the community-engaged mixed methods Georgia Doula Study, this analysis examines the scope of work of community-based doulas regarding full spectrum and abortion services, doula opinions on full spectrum and abortion work, and potential barriers and facilitators for full spectrum doula care in metro-Atlanta, Georgia. Methods: From October 2020 to February 2022, the team recruited 20 community-based doulas with 8 who provide full spectrum services including abortion. Surveys covered demographics, doula scope of work, family planning attitudes, and abortion stigma. Survey data were analyzed using descriptive and bivariate statistics. In-depth interviews further explored those topics. They were de-identified and thematically analyzed using a semi-deductive approach. Results: The findings are organized around five themes: (1) doulas of all kinds center reproductive autonomy; (2) abortion doulas play important roles in reproductive autonomy; (3) doulas have mixed feelings about contraceptive counseling; (4) abortion doulas provide diverse services carrying numerous benefits in a stigmatized environment; and (5) abortion doulas experience challenges including stigma but they offer solutions. All but two doulas in this study were interested in learning how to incorporate contraception and abortion services in their current scope of work, and most participants supported the role of full spectrum doulas. Conclusion: This analysis highlights the experiences of abortion and full spectrum doulas, reactions of the larger doula community to those services, and facilitators and barriers to full spectrum doula care in a restrictive abortion setting. There are urgent needs and opportunities for full spectrum doulas to offer life-protecting services to pregnant people across the U.S. and globally. Coordination efforts for U.S. abortion care post-Roe v. Wade must include community-based doulas, who are largely open to aiding abortion clients through education, connection to care, and emotional support.

"We really are seeing racism in the hospitals": Racial identity, racism, and doula care for diverse populations in Georgia.

INTRODUCTION: Poor birth outcomes are more prevalent for Black communities, but strong evidence shows that doula care can improve those outcomes. More evidence is needed to understand racial differences, discrimination, and equity in doula care. METHODS: The current study's objective was to describe the experiences of Black doulas as well as the challenges and facilitators of providing doula care to communities of color in Georgia. From Fall 2020-Fall 2021, 20 surveys and in-depth interviews were conducted with doulas as part of a community-based participatory study co-led by Healthy Mothers, Healthy Babies Coalition of Georgia and academic researchers. RESULTS: Doula participants were diverse in age (5% under 25, 40% 25-35, 35% 36-45, and 20% 46+) and race/ethnicity (45% white, 50% Black, 5% Latinx). Most (70%) Black doulas reported that more than 75% of their clientele is Black, while most (78%) white doulas reported that less than 25% of their clientele is Black. Doulas noted the alarming Black maternal mortality rate and how mistreatment causes Black clients to lose trust in medical staff, leaving them in need of advocates. Black doulas were passionate about serving and advocating with Black clients. Participants also described how language and cultural barriers, particularly for Asian and Latinx people, reduce clients' ability to self-advocate, increasing the need for doulas. Doulas also discussed the ways that race influences their connections with clients and their dissatisfaction with the lack of cultural humility or sensitivity training in standard doula training. CONCLUSION: Our findings indicate that Black doulas provide essential and supportive services to Black birthing people, and those services are more urgently needed than ever following the overturn of Roe v. Wade. Doula training must be improved to address the cultural needs of diverse clients. Increasing access to doula care for Asian and Latinx communities could also address language and cultural barriers that can negatively impact their maternal and child health outcomes.

"I want to serve those communities [but] my price tag is not what they can afford": The community-engaged Georgia doula study.

INTRODUCTION: In Georgia, maternal mortality is relatively high, and Black women are three times as likely to die from pregnancy-related causes as white women. Doulas can improve perinatal health and reduce disparities, but doula accessibility in Georgia is unclear. METHODS: This community-engaged mixed methods study surveyed and interviewed 17 doulas in Georgia. Surveys included structured questions on demographics, businesses, clientele, training, and challenges; we analyzed them using descriptive statistics. In-depth interviews included open-ended questions on doula care benefits, building their businesses, and improving access to doula care. We analyzed the content of transcripts using coding and memoing. RESULTS: Our diverse doula participants described providing life-saving services including education, referral to care, and patient advocacy. Yet they described numerous challenges to providing care and building their businesses. Almost all participants reported having fewer than their ideal number of clients and all reported being insufficiently paid for their services. Although training, mentoring, and networking help build their businesses, many doulas want to serve Black women, transgender men, gender non-binary individuals, and families living on lower incomes. Participants suggested Medicaid reimbursement and community health worker models as potential interventions for increasing equitable doula care access. DISCUSSION: Doulas can improve perinatal health outcomes and are urgently needed. Yet they face challenges in building businesses and finding clientele, especially from communities and groups at highest risk of negative outcomes during pregnancy, childbirth, and the postpartum period. Identifying avenues for supporting publicly-funded reimbursement, expanding equity-focused doula training, and fostering stronger doula networks with mentorship appears warranted.

Development of My Decision/Mi Decisión, a web-based decision aid to support permanent contraception decision making.

Objective: To develop a patient-centered, web-based decision aid to support informed and value-concordant decision making among Medicaid enrollees considering tubal sterilization. Methods: We used the Ottawa Decision Support Framework and the International Patient Decision Aids Standards (IPDAS) to guide systematic development of our decision aid. We interviewed 15 obstetrician-gynecologists and 40 women, who had considered or were considering tubal sterilization. A Steering Committee-comprising healthcare providers, social scientists, reproductive health and justice advocates, and people with lived experience-provided feedback and direction. We developed English and Spanish prototypes, which were beta tested with 24 women. Results: The resulting web-based My Decision/Mi Decisión tool (English/Spanish) includes written and video information about tubal sterilization procedures; an interactive table of contraception options; values clarification exercises; reflection and deliberation; knowledge checks; and a summary report to share with one's provider. Users found the decision aid to be informative, engaging, easy to use, and helpful in informing contraception decision making. Conclusion: My Decision/Mi Decisión is a scalable tool that could be implemented widely to support informed decision making about tubal sterilization. Innovation: This is a novel and timely web-based decision tool for tubal sterilization, when demand for permanent contraception is rapidly increasing post-Dobbs. While designed for Medicaid enrollees, further investigation will explore more generalized use.

U.S. physicians' perspectives on the complexities and challenges of permanent contraception provision.

OBJECTIVES: Evidence shows many misconceptions exist around permanent contraception, and there are numerous barriers to accessing the procedure. This qualitative study explored physician perspectives regarding patients' informational and decision-support needs, the complexities and challenges of counseling and access, and how these factors may differ for people living on lower incomes. STUDY DESIGN: We conducted 15 semistructured, telephone interviews with obstetrician-gynecologists in three geographic regions of the United States to explore their perspectives on providing permanent contraception counseling and care. We analyzed the interviews using content analysis. RESULTS: Physicians discussed a tension between respecting individual reproductive autonomy and concern for future regret; they wanted to support patients' desire for permanent contraception but were frequently concerned patients did not have the information they needed or the foresight to make high-quality decisions. Physicians also identified barriers to counseling including lack of time, lack of continuity over the course of prenatal care, and baseline misinformation among patients. Physicians identified additional barriers in providing a postpartum procedure even after thedecision was made including lack of personnel and operating room availability. Finally, physicians felt that people living on lower incomes faced more challenges in access primarily due to the sterilization consent regulations required by Medicaid. CONCLUSIONS: Physicians report numerous challenges surrounding permanent contraception provision and access. Strategies are needed to support physicians and patients to enhance high-quality, patient-centered sterilization decision making and ensure that patients are able to access a permanent contraceptive procedure when desired. IMPLICATIONS: This qualitative study demonstrates the various challenges faced by physicians to support permanent contraception decision making. These challenges may limit patients' access to the care they desire. This study supports the need to transform care delivery models and improve the federal sterilization policy to ensure equitable patient-centered access to desired permanent contraception. DISCLAIMER: Although the term permanent contraception has increasingly replaced the word sterilization in clinical settings, we use sterilization in some places throughout this paper as that was the standard terminology at the time the interviews were conducted and the language the interviewed physicians used.

"The right thing to do would be to provide care and we can't": Provider experiences with Georgia's 22-week abortion ban.

OBJECTIVES: In 2015, the Georgia (US) legislature implemented a gestational limit, or "ban" on abortion at or beyond 22 weeks from the last menstrual period. In this study, we qualitatively examined abortion provider perspectives on the ban's impact on abortion care access and provision. STUDY DESIGN: Between May 2018 and September 2019, we conducted in-depth individual interviews with 20 abortion providers (clinicians, staff, and administrators) from four clinics in Georgia. Interviews explored perceptions of and experiences with the ban and its effects on abortion care. Team members coded transcripts to 100% agreement using an iterative, group consensus process, and conducted a thematic analysis. RESULTS: Participants reported strict adherence to the ban and also its negative consequences: additional labor plus service-delivery restrictions, legally constructed risks for providers, intrusion into the provider-patient relationship, and impact of limited services felt by patients and, thus, providers. Participants commonly mentioned disparities in the ban's impact and viewed the ban as disproportionately affecting people of color, those experiencing financial insecurity, and those with underlying medical conditions. Nonetheless, participants described a clear, unrelenting commitment to providing quality patient-centered care and dedication to and satisfaction in their work. CONCLUSIONS: Georgia's ban operates as legislative interference, adversely affecting the provision of quality, patient-centered abortion care, despite providers' resilience and commitment. These experiences in Georgia have timely and clear implications for the entire country following the Supreme Court's decision to overturn Roe v Wade, thus reducing care access and increasing negative health and social consequences and inequities for patients and communities on a national scale. IMPLICATIONS: Our findings from Georgia (US) indicate an urgent need for coordinated efforts to challenge the Dobbs v Jackson Women's Health Organization decision and for proactive policies that protect access to later abortion care. Research that identifies strategies for supporting providers and patients faced with continuing restrictive legal environments is warranted.

Teen Well Check: an e-health prevention program for substance use, sexual assault, and sexual risk behaviors for adolescents in primary care.

Objective: Adolescents are at risk for substance use, sexual assault, and sexual risk behaviours; however, to date no integrated prevention programmes address all three risk behaviours. The goal of this study was to evaluate the usability and acceptability of Teen Well Check, an e-health prevention programme targeting substance use, sexual assault, and sexual risk among adolescents in primary care settings.Methods: The current study included content analysis of interviews with adolescents in primary care (aged 14-18; n = 25) in the intervention development process, followed by usability and acceptability testing with qualitative interviews among adolescents in primary care (aged 14-18; n = 10) and pediatric primary care providers (n = 11) in the intervention refinement process. All data were collected in the Southeastern U.S.Results: Feedback on Teen Well Check addressed content, engagement and interaction, language and tone, aesthetics, logistics, inclusivity, parent/guardian-related topics, and the application of personal stories. Overall, providers reported they would be likely to use this intervention (5.1 out of 7.0) and recommend it to adolescents (5.4 out of 7.0).Conclusions: These findings suggest preliminary usability and acceptability of Teen Well Check. A randomized clinical trial is needed to assess efficacy.

Adolescents are at risk for substance use, sexual assault, and sexual risk behaviours.The goal of this study was to evaluate the usability and acceptability of Teen Well Check, an e-health prevention programme targeting substance use, sexual assault, and sexual risk among adolescents in primary care settings.Providers and adolescents rated Teen Well Check as usable and acceptable, and providers indicated that they would recommend it to their adolescent patients.

Estimation of Multiyear Consequences for Abortion Access in Georgia Under a Law Limiting Abortion to Early Pregnancy.

Importance: Following the US Supreme Court ruling in Dobbs v Jackson Women's Health Organization, Georgia's law limiting abortion to early pregnancy, House Bill 481 (HB481), was allowed to go into effect in July 2022. Objectives: To estimate anticipated multiyear effects of HB481, which prohibits abortions after detection of embryonic cardiac activity, on abortion incidence in Georgia, and to examine inequities by race, age, and socioeconomic status. Design, Setting, and Participants: This repeated cross-sectional analysis used abortion surveillance data from January 1, 2007, to December 31, 2017, to estimate future effects of HB481 on abortion care in Georgia, with a focus on the 2 most recent years of data (2016 and 2017). Abortion surveillance data were obtained from the 2007-2017 Georgia Department of Public Health's Induced Termination of Pregnancy files. Linear regression was used to estimate trends in abortions provided at less than 6 weeks' gestation and at 6 weeks' gestation or later in Georgia, and χ2 analyses were used to compare group differences by race, age, and educational attainment. Data were analyzed from July 26 to September 22, 2022. Exposures: HB481, Georgia's law limiting abortion to early pregnancy. Main Outcome and Measures: Weeks' gestation at abortion (<6 vs ≥6 weeks). Results: From January 1, 2007, to December 31, 2017, there were 360 972 reported abortions in Georgia, with an annual mean (SD) of 32 816 (1812) abortions. Estimates from 2016 to 2017 suggest that 3854 abortions in Georgia (11.6%) would likely meet eligibility requirements for abortion care under HB481. Fewer abortions obtained by Black patients (1943 [9.6%] vs 1280 [16.2%] for White patients), patients younger than 20 years (261 [9.1%] vs 168 [15.0%] for those 40 years and older), and patients with fewer years of education (392 [9.2%] with less than a high school diploma and 1065 [9.6%] with a high school diploma vs 2395 [13.5%] for those with some college) would likely meet eligibility requirements under HB481. Conclusions and Relevance: These findings suggest that Georgia's law limiting abortion to early pregnancy (HB481) would eliminate access to abortion for nearly 90% of patients in Georgia, and disproportionately harm patients who are Black, younger, and in lower socioeconomic status groups.

"They're forcing people to have children that they can't afford": a qualitative study of social support and capital among individuals receiving an abortion in Georgia.

Abortion is common but highly stigmatized in the United States, and the overturning of Roe v. Wade severely restricted abortion access in many states across the nation. Data reveal that maternal morbidity and mortality are already increasing, and research suggests existing inequities in abortion access across racial/ethnic and socioeconomic groups will be exacerbated. Research has shown that social support (perceived and received aid from one's social network) and social capital (resources accessed through those social connections) can improve access to health services and decrease barriers to care. Given the escalating barriers to abortion, including longer travel distances, it is imperative to better understand the roles of social support and social capital within abortion access, especially for people living on lower incomes and people of color. Our team conducted in-depth interviews with post-abortion patients (n = 18) from an urban abortion clinic in Georgia in 2019 and 2020, shortly after a six-week gestational age abortion limit had been passed but before it was enacted. We examined how people described their social support and social capital - or lack thereof - when making decisions about their pregnancy and their ability to access abortion. We found that social support and social capital - economic support in particular - were key facilitators of both abortion access and parenting, but participants often experienced barriers to economic support within their social networks due to poverty, unstable partnerships, structural inequality, and abortion stigma. Women experienced constraints to their reproductive autonomy, wherein they had no alternatives but abortion. Our findings suggest that increased economic support and de-stigmatization of abortion are needed to improve reproductive autonomy. Our findings also indicate that restricting and outlawing abortion services is significantly detrimental to the well-being of pregnant people, their families and networks, and their communities by perpetuating cycles of poverty and deepening socioeconomic and racial/ethnic inequities.