"I probably have access, but I can't afford it": expanding definitions of affordability in access to contraceptive services among people with low income in Georgia, USA.

BACKGROUND: Disparities in rates of contraceptive use are frequently attributed to unequal access to and affordability of care. There is a need to better understand whether common definitions of affordability that solely relate to cost or to insurance status capture the reality of individuals' lived experiences. We sought to better understand how individuals with low incomes and the capacity for pregnancy conceptualized one domain of contraceptive access-affordability --in terms of health system and individual access and how both shaped contraceptive care-seeking in the US South. METHOD: Between January 2019 to February 2020, we conducted twenty-five life-history interviews with low-income individuals who may become pregnant living in suburban counties in Georgia, USA. Interviews covered the ways individual and health system access factors influenced care-seeking for family planning over the life course. Interview transcripts were analyzed using a thematic analysis approach to identify experiences associated with individual and health system access. RESULTS: Affordability was identified as a major determinant of access, one tied to unique combinations of individual factors (e.g., financial status) and health system characteristics (e.g., cost of methods) that fluctuated over time. Navigating the process to attain affordable care was unpredictable and had important implications for care-seeking. A "poor fit" between individual and health system factors could lead to inequities in access and gaps in, or non-use of contraception. Participants also reported high levels of shame and stigma associated with being uninsured or on publicly funded insurance. CONCLUSIONS: Affordability is one domain of contraceptive access that is shaped by the interplay between individual factors and health system characteristics as well as by larger structural factors such as health and economic policies that influence both. Assessments of the affordability of contraceptive care must account for the dynamic interplay among multilevel influences. Despite the expansion of contraceptive coverage through the Affordable Care Act, low-income individuals still struggle with affordability and disparities persist.

Extra-legal abortion and post-abortion care knowledge, attitudes, and practices among obstetrician-gynecologist clinicians and medical residents in San José, Costa Rica: a qualitative study.

BACKGROUND: Induced abortion in Costa Rica is illegal in all cases except to save the life of the pregnant person. Despite severe restrictions to legal abortion, individuals in Costa Rica still induce abortions outside of the formal healthcare system. These individuals and those with spontaneous abortions, also known as miscarriages, occasionally need medical care for complications. In Costa Rica, an estimated 41% of unintended pregnancies end in abortion, yet there is very little published literature exploring the perspectives of healthcare providers on abortion in Costa Rica. METHODS: We interviewed ten obstetrician-gynecologist clinicians and five obstetrician-gynecologist medical residents in San José, Costa Rica about their beliefs and practices related to extra-legal abortion and post-abortion care (PAC) using a Spanish language in-depth semi-structured interview guide. After transcription and translation into English, analysis team pairs used a combination of deductive and inductive coding to identify themes and sub-themes within the data. RESULTS: Obstetrician-gynecologist clinicians and medical residents were aware of the presence of extra-legal abortion, and particularly, medication abortion, in their communities, but less familiar with dosing for induction. They expressed the desire to provide non-judgmental care and support their patients through extra-legal abortion and PAC journeys. Study participants were most familiar with providing care to individuals with spontaneous abortions. When discussing PAC, they often spoke about a policy of reporting individuals who seek PAC following an extra-legal abortion, without commenting on whether or not they followed the guidance. CONCLUSIONS: This study contributes to a gap in research about the knowledge, attitudes, and practices of Costa Rican obstetrician-gynecologist clinicians and medical residents around extra-legal abortion and PAC. The results reveal an opportunity to train these healthcare providers as harm reduction experts, who are able to accurately counsel individuals who are seeking abortion services outside of the healthcare system, and to provide training to improve care for individuals needing PAC.

"No One Does This for the Money or Lifestyle": Abortion Providers' Perspectives on Factors Affecting Workforce Recruitment and Retention in the Southern United States.

OBJECTIVES: Movements to stem abortion accessibility and provision are underway across the southern United States. Preserving access to safe abortion requires a steady maternal health workforce. Targeted laws and limiting environments have contributed to a regional dearth of abortion providers. This study evaluates the consequences of restrictive environments for the abortion workforce to inform strategies to reduce the provider shortage in the South. METHODS: We recruited twelve physicians using purposive sampling and interviewed them on their motivations and experiences practicing in the South. We employed grounded theory analysis to translate their perspectives into recommendations for provider recruitment and retention. RESULTS: Abortion providers identified challenges relating to restrictive legislation, institutional separation of abortion from other medical services, training unavailability, safety concerns, identity struggles, and marginalization within their profession. This contributed to providers widely experiencing stigma and isolation within their work and life environments. Their motivations for practicing in the South despite these challenges included wanting to be impactful in areas of high need, combating health access disparites, and having personal ties to the region. Providers' suggested increasing regional networking and training opportunities, creating an information clearinghouse, and offering additional compensation to better support their work. We conceptualized these findings into a framework detailing the challenges, impacts and opportunities for abortion provision in the southern United States. CONCLUSIONS FOR PRACTICE: Our recommendations for provider recruitment and retention include cooperation between professional organizations, training programs, and healthcare institutions to create opportunities for training and networking and encourage abortion-supportive organizational and policy environments.

Supporting Staff in Southern Family Planning Clinics: Challenges and Opportunities.

OBJECTIVES: The aim of this study was to identify key challenges and opportunities to better support non-clinician clinic staff at family planning centers in Southern US states. METHODS: We conducted qualitative interviews with 15 individuals in clinic staff and leadership positions at family planning centers in seven Southern states. RESULTS: Turnover had negative impacts on both clinic functioning as well as patient care. Participants identified several challenges related to recruitment and retention in family planning health centers in the South, including the conservative contextual landscape, the perceived value of support staff, gaps in communication, and rural locations. In response to these challenges, staff also identified key strategies to better support and retain health center workers. These included prioritizing investment in management, creating career advancement opportunities, prioritizing staff retention, and creating space for self-care. Health center staff and leadership who used these strategies to support and retain staff noted improvements in the effectiveness of staff work as well as increases in patient volume. CONCLUSIONS FOR PRACTICE: Study findings provide key areas for intervention including providing development opportunities, commitment from leadership to recognize and invest in staff and supporting self-care. Focusing on ensuring internal organizational justice for staff may also facilitate resilience to external challenging environments. Better supporting clinic staff is likely also important for quality services and ensures the full workforce involved in providing family planning care can work at full capacity.

Help and Care Seeking for Sexually Transmitted Infections Among Youth in Low- and Middle-Income Countries.

BACKGROUND: The ability to seek help or medical care for sexually transmitted infections (STIs) is vital for sexually active youth; yet, their needs are often unmet. METHODS: We conducted a qualitative systematic review of studies to assess youth and provider views about the behaviors of young people in help seeking and care seeking for STI services in low- and middle-income countries. We searched peer-reviewed literature for studies published between 2001 and 2014 with a study population of youth (age, 10-24 years) and/or health service providers. Eighteen studies were identified for inclusion from 18 countries. Thematic analyses identified key themes across the studies. RESULTS: The majority of studies included discussion of youth not seeking treatment, resorting to self-treatment, or waiting to access care, suggesting that many youth still do not seek timely care for STIs. Youth desired more information on sexual health and cited barriers related to fear or taboos in obtaining help or information, especially from providers or parents. Many did not recognize symptoms or waited until symptoms worsened. However, many youth were able to identify a number of sources for STI related care including public and private clinics, pharmacies, alternative healers, and nongovernmental organizations. Youth's help seeking and care seeking preferences were frequently influenced by desires for confidentiality, friendliness, and cost. CONCLUSIONS: Youth in low- and middle-income countries experience significant barriers in help seeking for STIs and often do not seek or postpone medical care. Improving uptake may require efforts to address clinic systems, provider attitudes, confidentiality, and cultural norms related to youth sexuality.

'People insult her as a sexy woman': sexuality, stigma and vulnerability among widowed and divorced women in Oromiya, Ethiopia.

Widowed and divorced women, sometimes referred to as 'female heads of household', are one of the most impoverished and marginalised groups in the world. Widowed and divorced women are often overlooked in the literature or are seen primarily as economically or socially marginalised beings; their sexuality is rarely addressed. In an effort to understand the experiences and challenges faced by such women, we conducted and analysed four focus-group discussions, seven in-depth interviews and four interactive activities with 32 widowed and divorced women and with 25 other community members in Oromiya, Ethiopia. Findings indicate that women experienced high levels of community stigma in relation to their sexuality. Participants' fear of community stigma, and the actions they took to avert it, further served to marginalise them within their community and had negative impact on their economic, social and health support systems and, ultimately, on their overall well-being. Future interventions need to acknowledge sexual stigma as a driving force in the many challenges these women face. Further programmatic work is needed to reduce stigma related to widowed and divorced women's sexuality and to decrease their vulnerability to rape.

"So that I can trust them with my body:" How people with low incomes who may become pregnant define and prioritize quality reproductive health care.

OBJECTIVES: As part of a larger mixed-methods study to better define equity in access to sexual and reproductive health (SRH) care in Georgia, this analysis sought to understand: (1) how individuals define quality care for their SRH services; and (2) how quality of care is salient in their SRH care-seeking. STUDY DESIGN: From January 2019 to February 2020, we conducted life history interviews with individuals with the capacity to become pregnant in suburban areas in Georgia. We analyzed interviews using thematic analysis. RESULTS: SRH care quality was shaped by experiences with health center environment, with providers, and with staff. Study participants emphasized elements associated with trusted SRH care such as showing compassion, respecting and non-judging, taking time, providing information, and assuring agency. Participants also voiced a desire for holistic care that addressed the lived experiences of the individual. Participants took quality of care into account when care-seeking but sometimes had to weigh out preferences for quality with issues of affordability. CONCLUSIONS: Access to quality person-centered care is an essential component of realized access to SRH services. Measures of equitable access and quality should account for experiences of quality care that include both provider and staff interactions as well as the larger healthcare environment and ability to use quality care despite financial constraints. IMPLICATIONS: Quality family planning care should involve both clinicians and staff to incorporate showing compassion, providing respectful and non-judgmental care, taking time with patients, providing information, assuring agency in decision-making, as well as addressing the lived experiences of individuals.

Implementation of Title X Family Planning Services in Primary Care: A Qualitative Study of a Primary Care Network in Georgia.

CONTEXT: There is increasing interest and value in integrating family planning services into primary care. Title X services provide an opportunity to expand low-cost access to these services. This study sought to identify and describe implementation factors that influenced the integration of a package of Title X services into a unique primary care setting within a Georgia primary care network whose community health center sites are primarily federally qualified health centers. METHODS: We used an implementation science approach and were guided by the Consolidated Framework for Implementation Research. From December 2019 to September 2020, we conducted interviews with administrators and providers working at grantee and sub-grantee organizations about their experiences integrating Title X services into their existing practice. RESULTS: Factors associated with the Inner Setting were especially important for integrating Title X in these settings. Participants identified specific needs related to resources such as electronic medical record (EMR) and reporting templates. Contextually specific clinical training for provision of long-acting reversible contraception and sexual health counseling, as well as administrative training for reporting and documentation efforts, was particularly needed. Grantee and sub-grantee organizations were able to leverage internal and external networks and adaptations to the intervention to successfully implement Title X services and to expand reach to new clients. CONCLUSIONS: Integrating family planning into primary care may expand access to low-income and underserved populations. Approaches that incorporate flexibility and provide tailored resources for primary care settings such as EMR and reporting templates and trainings, and that leverage multiple forms of support and knowledge sharing, may be particularly important for helping to implement Title X services.

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.

"Post-Roe" Abortion Policy Context Heightens the Imperative for Multilevel, Comprehensive, Integrated Health Education.

The exceptionalism of abortion in public health education, due to social stigma, politicization, and lack of training, contributes to misinformation, policies unjustified by rigorous science, lack of access to person-centered health care, and systemic pregnancy-related inequities. Now that abortion access has vanished for large portions of the United States, following the Supreme Court decision in Dobbs v. Jackson Women's Health Organization (JWHO), health educators must work to eliminate abortion-related silos, destigmatize abortion education, and bring comprehensive sexual and reproductive health information and evidence to the many audiences that will require it. We discuss consequences of abortion exceptionalism in health education for the public, health care providers, pregnant people, and health professionals in training-and opportunities to better and more accessibly provide sexual and reproductive health education to these audiences.

Is it COVID-19? The value of medicolegal autopsies during the first year of the COVID-19 pandemic.

OBJECTIVES: We describe the experience of a busy metropolitan medical examiner's office in the United States and share our navigation of the COVID-19 autopsy decision-making process. We describe key gross and microscopic findings that, with appropriate laboratory testing, should direct a pathologist towards a COVID-19-related cause of death. MATERIAL AND METHODS: We performed a retrospective review of 258 suspected and/or confirmed COVID-19 associated deaths that occurred between March 5, 2020, and March 4, 2021. RESULTS: A total of 62 cases due to fatal COVID-19 were identified; autopsy findings included diffuse alveolar damage, acute bronchopneumonia and lobar pneumonia, and pulmonary thromboemboli. Nine additional decedents had a nasopharyngeal swab positive for SARS-CoV-2 and a cause of death unrelated to COVID-19. Forty-seven cases with COVID-19-like symptoms showed no laboratory or histopathologic evidence of SARS-CoV-2 infection; the most common causes of death in this group were hypertensive or atherosclerotic cardiovascular disease, complications of chronic alcoholism, and pulmonary thromboemboli unrelated to infection. CONCLUSIONS: The clinical findings associated with COVID-19 are not specific; a broad differential diagnosis should be embraced when decedents present with cough or shortness of breath. An autopsy may be indicated to identify a cause of death unrelated to COVID-19.

Influences on Women's Care Seeking at Planned Parenthood Health Centers in Two Southern States.

INTRODUCTION: In the context of a shifting health care landscape, better understanding of the factors that motivate women to seek services from specialized family planning clinics like Planned Parenthood (PP) can provide insights about potential changes in the role of specialized family planning clinics. METHODS: We surveyed 725 women seeking services at two PP health centers in Louisiana and Kentucky from March 2016 to May 2017. We examined differences in care-seeking between women who had varying levels of access including those who did and did not have insurance instability or a regular source of care (RSOC) besides the clinic. RESULTS: More than 60% of women attending the health centers did not have a regular source of care and nearly 40% experienced instability in insurance. Women who experienced insurance instability and a lack of a regular source of care more frequently sought primary preventive services such as pap tests and well-woman care at PP than women with better access. For women with better access, PP health centers also served important roles for those seeking contraceptive and sexually transmitted infection-related services. The most frequent reasons for choosing PP were that it was faster to get an appointment, wanting to go to the PP clinic more than other clinics, and the confidentiality of services. CONCLUSIONS: Our analysis suggests that PP health centers in Southern states still provide vital services for women with and without other sources of care and are critical for women needing access to timely services for preventive and sexually transmitted infection-related care.

Context matters: Using mixed methods timelines to provide an accessible and integrated visual for complex program evaluation data.

The need for conducting evaluations which reflect of the influence of context on complex programs is increasingly recognized in the field of evaluation. Better data visualization techniques for connecting context with program evaluation data are needed. We share our experience developing a mixed methods timeline to visualize complexity and context with evaluation data. Mixed methods timelines provide a meaningful way to show change over time in both a visually stimulating and accessible format for evaluation audiences. This paper provides an innovative example of using mixed methods timelines to integrate evaluation data with key program activities and milestones, while also showing internal and external contextual influences in one cohesive visual. We present methods and best practices for collecting contextual data and for incorporating a variety of data sources into such a visual. We discuss several strategies to collect and organize context related data including: qualitative interviews, program materials, narrative reports, and member checking with stakeholders and staff. Gathering multiple perspectives is essential to better capture the multi-layered elements of program activities and context.

Contraceptive information on pregnancy resource center websites: a statewide content analysis.

OBJECTIVE: Most pregnancy resource centers (PRCs) in the US are affiliated with national organizations that have policies against promoting or providing contraceptives, yet many provide information about contraception on their websites. In 2016, the state of Georgia passed a new law to publicly fund PRCs. This study sought to describe the contraceptive information on Georgia PRC websites. STUDY DESIGN: We systematically identified all accessible Georgia PRC websites April-June 2016. We downloaded entire websites and used defined protocols to code and thematically analyze content about contraceptives. RESULTS: Of the 64 websites reviewed, 20 (31%) presented information about contraceptives. Most of the content was dedicated to emergency contraception. Emphasis on risks and side effects was the most prominent theme. However, no site presented information about the frequency or prevalence of risks and side effects. Sites also emphasized contraceptive failure and minimized effectiveness. We found a high degree of inaccurate and misleading information about contraceptives. CONCLUSIONS: Georgia PRC websites presented skewed information that may undermine confidence in the safety and efficacy of contraceptive methods and discourage use. Public funding for PRCs, an increasing national trend, should be rigorously examined. Increased regulation is urgently needed to ensure that online information about contraceptives presented by publicly funded centers is unbiased, complete and accurate. IMPLICATIONS: We examined contraceptive information on Georgia PRC websites and found sites minimize benefits and emphasize barriers to use. They contain high levels of medically inaccurate and misleading information that may undermine public health goals. Public funding for PRCs should be rigorously examined; increased regulation is urgently needed.

Sexual and Reproductive Health Services and Related Health Information on Pregnancy Resource Center Websites: A Statewide Content Analysis.

BACKGROUND: Pregnancy resource centers (PRCs) are nonprofit organizations with a primary mission of promoting childbirth among pregnant women. Given a new state grant program to publicly fund PRCs, we analyzed Georgia PRC websites to describe advertised services and related health information. METHODS: We systematically identified all accessible Georgia PRC websites available from April to June 2016. Entire websites were obtained and coded using defined protocols. RESULTS: Of 64 reviewed websites, pregnancy tests and testing (98%) and options counseling (84%) were most frequently advertised. However, 58% of sites did not provide notice that PRCs do not provide or refer for abortion, and 53% included false or misleading statements regarding the need to make a decision about abortion or links between abortion and mental health problems or breast cancer. Advertised contraceptive services were limited to counseling about natural family planning (3%) and emergency contraception (14%). Most sites (89%) did not provide notice that PRCs do not provide or refer for contraceptives. Two sites (3%) advertised unproven "abortion reversal" services. Approximately 63% advertised ultrasound examinations, 22% sexually transmitted infection testing, and 5% sexually transmitted infection treatment. None promoted consistent and correct condom use; 78% with content about condoms included statements that seemed to be designed to undermine confidence in condom effectiveness. Approximately 84% advertised educational programs, and 61% material resources. CONCLUSIONS: Georgia PRC websites contain high levels of false and misleading health information; the advertised services do not seem to align with prevailing medical guidelines. Public funding for PRCs, an increasing national trend, should be rigorously examined. Increased regulation may be warranted to ensure quality health information and services.

Sexually Transmitted Infection Services for Adolescents and Youth in Low- and Middle-Income Countries: Perceived and Experienced Barriers to Accessing Care.

PURPOSE: Access to sexual and reproductive health (SRH) services is vital for sexually active adolescents; yet, their SRH care needs are often unmet. METHODS: We conducted a qualitative systematic review of mixed methods studies to assess adolescent and provider views of barriers to seeking appropriate medical care for sexually transmitted infection (STI) services for adolescents. We searched peer-reviewed literature for studies published between 2001 and 2014 with a study population of youth (aged 10-24 years) and/or health service providers. Nineteen studies were identified for inclusion from 15 countries. Thematic analyses identified key themes across the studies. RESULTS: Findings suggest that youth lacked knowledge about STIs and services. In addition, youth experienced barriers related to service availability and a lack of integration of services. The most reported barriers were related to acceptability of services. Youth reported avoiding services or having confidentiality concerns based on provider demographics and some behaviors. Finally, experiences of shame and stigma were common barriers to seeking care. CONCLUSIONS: Adolescents in low- and middle-income countries experience significant barriers in obtaining STI and SRH services. Improving uptake may require efforts to address clinic systems and provider attitudes, including confidentiality issues. Moreover, addressing barriers to STI services may require addressing cultural norms related to adolescent sexuality.

Sexually Transmitted Infection Testing Among Adolescents and Young Adults in the United States.

PURPOSE: Persons aged 15-25 years have high sexually transmitted infection (STI) rates and suboptimal screening. There has been limited research analyzing barriers to STI testing at a national level. We examined STI testing among 15-25 year olds and reasons for not testing. METHODS: We used data from a national survey of youth. Bivariate and multivariable analyses examined differences in testing behaviors by demographics, separately by sex. Among sexually experienced respondents who reported never being tested, health system-related reasons for not testing were examined in bivariate and multivariable analyses. RESULTS: Females (16.6%) were more likely to have ever been tested compared with males (6.1%, p < .01) in the last 12 months. Among sexually experienced respondents who were never tested, 41.8% did not seek testing because they felt they were not at risk for STIs. Males (60.1%) had significantly higher reports of foregoing testing for confidentiality reasons compared with females (39.9%, p < .01). Non-Hispanic whites (44.9%) the highest reports of this compared with other ethnic/racial groups (p < .01). CONCLUSIONS: This national-level study found that most of the 15-25 year olds never received an STI test. In addition, confidentiality concerns may deter youth from seeking STI testing. Appropriate strategies to minimize these concerns may be useful. Potential strategies to ameliorate these issues may include engaging clinicians who frequently serve adolescents and young adults to address confidentiality issues with youth patients.