Health-care workforce implications of the Dobbs v Jackson Women's Health Organization decision.

The Dobbs v Jackson Women's Health Organization Supreme Court decision, which revoked the constitutional right to abortion in the USA, has impacted the national medical workforce. Impacts vary across states, but providers in states with restrictive abortion laws now must contend with evolving legal and ethical challenges that have the potential to affect workforce safety, mental health, education, and training opportunities, in addition to having serious impacts on patient health and far-reaching societal consequences. Moreover, Dobbs has consequences on almost every facet of the medical workforce, including on physicians, nurses, pharmacists, and others who work within the health-care system. Comprehensive research is urgently needed to understand the wide-ranging implications of Dobbs on the medical workforce, including legal, ethical, clinical, and psychological dimensions, to inform evidence-based policies and standards of care in abortion-restrictive settings. Lessons from the USA might also have global relevance for countries facing similar restrictions on reproductive care.

Societal implications of the Dobbs v Jackson Women's Health Organization decision.

On June 24, 2022, the US Supreme Court's decision in Dobbs v Jackson Women's Health Organization marked the removal of the constitutional right to abortion in the USA, introducing a complex ethical and legal landscape for patients and providers. This shift has had immediate health and equity repercussions, but it is also crucial to examine the broader impacts on states, health-care systems, and society as a whole. Restrictions on abortion access extend beyond immediate reproductive care concerns, necessitating a comprehensive understanding of the ruling's consequences across micro and macro levels. To mitigate potential harm, it is imperative to establish a research agenda that informs policy making and ensures effective long-term monitoring and reporting, addressing both immediate and future impacts.

Opioid use disorder at delivery hospitalization in the United States: 2012-2016.

BACKGROUND AND OBJECTIVES: The objective of this paper is to evaluate national trends, socioeconomic risk factors, and maternal and obstetric outcomes for patients with and without opioid use disorder (OUD) at delivery hospitalization. METHODS: This is a retrospective cohort using the National Inpatient Sample 2012-2016 of 3,554,477 deliveries to analyze trends in OUD in patients at delivery hospitalization. We conducted univariable and multivariable logistic regression to compare clinical, demographic, hospital, and geographic associations for patients with OUD during delivery hospitalization. RESULTS: The incidence of OUD at delivery hospitalization increased from 4.48 per 1000 deliveries in 2012 to 7.67 in 2016. The highest rate of OUD was in the Northeast and the lowest in the West (9.29 vs. 4.13 per 1000, respectively, p < .001). After adjusting for confounders, history of concurrent cocaine use (adjusted odds ratio [aOR] = 5.95, 95% confidence interval [CI]: 5.38-6.59), sedative use (aOR = 17.28, 95% CI: 14.71-20.31), and amphetamine use (aOR = 4.05, 95% CI: 3.71-4.43), were strongly associated with OUD. Additionally, hepatitis C infection, (aOR = 21.98, 95% CI: 20.89-23.11), white race (aOR = 3.12, 95% CI: 3.00-3.24), and public insurance (aOR = 3.92, 95% CI: 3.77-4.08) were also associated with OUD. DISCUSSION AND CONCLUSION: The continued increase in rates of OUD at delivery hospitalization and its association with adverse perinatal outcomes highlights the need for universal screening and resource allocation for programs directed toward pregnant people. SCIENTIFIC SIGNIFICANCE: Our study builds upon the prior literature that reports trends in OUD at delivery hospitalization from 1998 to 2011 as well as presents a more in-depth look at risk factors and adverse pregnancy outcomes than previously reported.

Impact of Medical Students on Patient Satisfaction of Pregnant Women in Labor and Delivery Triage.

OBJECTIVES: Clinical rotations are an important aspect of undergraduate medical education. However, as patient satisfaction scores receive increasing attention, the impact of medical student participation on patient satisfaction and perception of quality of care is unclear. Previous studies from the Emergency Department and outpatient settings show that medical students do not negatively impact satisfaction scores. The authors sought to examine the effect of medical student involvement on patient satisfaction in the Labor and Delivery Triage setting. METHODS: The authors conducted a survey study of a convenience sample of pregnant patients seen in and discharged from Labor and Delivery between January 2015 and April 2016. Surveys addressed questions about the overall satisfaction with the care patients received, as well as other outcome measures such as comfort with asking questions, time spent with a physician, and politeness of staff. RESULTS: 240 total surveys were collected. After excluding surveys from those that were unsure whether a medical student was involved in their care, 168 surveys were used in the final analysis. Of these, 63.7% of subjects reported being seen by a medical student. There was no significant difference (p = 0.76) in overall patient satisfaction between groups. CONCLUSIONS FOR PRACTICE: Given the lack of a negative impact of medical student involvement on patient satisfaction, medical students should continue to be active members of the healthcare team, including in specialties such as obstetrics and locations such as Labor and Delivery triage with highly sensitive and time-dependent evaluations.

Supporting OB-GYNs in Abortion-Restrictive States-A Playbook for Institutions.

This Viewpoint provides proposed institutional practices, such as medicolegal collaboration and providing materials and resources, to support obstetrician-gynecologists (OB-GYNs) in abortion-restrictive states.

Medicaid Consent to Sterilization forms: historical, practical, ethical, and advocacy considerations.

The US government developed a Medicaid Consent to Sterilization form in the mid-1970s to protect vulnerable populations from coerced sterilization. US health care practices have evolved significantly since that time. The form, however, has not changed, and may be preventing access to desired services for the same vulnerable populations it was originally created to protect. This paper discusses the relevant historical, practical use, ethical, and advocacy considerations of the Medicaid sterilization consent form and proposes changes to make the form more pertinent to today's medical environment.

US Obstetrician-Gynecologists' Perceived Impacts of Post-Dobbs v Jackson State Abortion Bans.

Importance: Following the Dobbs v Jackson Women's Health Organization decision in June 2022, 17 US states have functionally banned abortion except in narrow circumstances, and physicians found in violation of these laws face felony charges, loss of their medical license, fines, and prison sentences. Patient impacts are being studied closely, but less research has focused on the consequences for obstetrician-gynecologists (OB-GYNs), for whom medically necessary care provision may now carry serious personal and professional consequences. Objective: To characterize perceptions of the impact of abortion restrictions on clinical practice, moral distress, mental health, and turnover intention among US OB-GYNs practicing in states with functional bans on abortion. Design, Setting, and Participants: This qualitative study included semistructured, remote interviews with OB-GYNs from 13 US states with abortion bans. Volunteer sample of 54 OB-GYNs practicing in states that had banned abortion as of March 2023. Exposure: State abortion bans enacted between June 2022 and March 2023. Main Outcomes and Measures: OB-GYNs' perceptions of clinical and personal impacts of abortion bans. Results: This study included 54 OB-GYNs (mean [SD] age, 42 [7] years; 44 [81%] female participants; 3 [6%] non-Hispanic Black or African American participants; 45 [83%] White participants) who practiced in general obstetrics and gynecology (39 [72%]), maternal-fetal medicine (7 [13%]), and complex family planning (8 [15%]). Two major domains were identified in which the laws affected OB-GYNs: (1) clinical impacts (eg, delays in care until patients became more sick or legal sign-off on a medical exception to the ban was obtained; restrictions on counseling patients on pregnancy options; inability to provide appropriate care oneself or make referrals for such care); and (2) personal impacts (eg, moral distress; fears and perceived consequences of law violation; intention to leave the state; symptoms of depression and anxiety). Conclusions and relevance: In this qualitative study of OB-GYNs practicing under abortion bans, participants reported deep and pervasive impacts of state laws, with implications for workforce sustainability, physician health, and patient outcomes. In the context of public policies that restrict physicians' clinical autonomy, organization-level supports for physicians are essential to maintain workforce sustainability, clinician health and well-being, and availability of timely and accessible health care throughout the US.

Modeling the impact of decreasing waiting period length for Medicaid sterilization: A multi-site cohort study.

OBJECTIVE: To evaluate the impact of length of the Medicaid sterilization waiting period and postpartum permanent contraception fulfillment. STUDY DESIGN: Simulations from a retrospective cohort study estimating the potential increase in permanent contraception within 365 days of delivery. RESULTS: In our sample of 2076 patients, 61% achieved permanent contraception with the current waiting period of 30 days. With the waiting period hypothetically reduced to 15, 3, 1, and 0 days, 62.9%, 63.7%, 64.5%, and 75% patients, respectively, would have achieved permanent contraception. CONCLUSIONS: As potential Medicaid sterilization policy revisions are considered, understanding the impact on fulfillment rates is critical.

Neighbourhood socioeconomic position, prenatal care and fulfilment of postpartum permanent contraception: Findings from a multisite cohort study.

Introduction: Research suggests neighbourhood socioeconomic vulnerability is negatively associated with women's likelihood of receiving adequate prenatal care and achieving desired postpartum permanent contraception. Receiving adequate prenatal care is linked to a greater likelihood of achieving desired permanent contraception, and access to such care may be critical for women with Medicaid insurance given that the federally mandated Medicaid sterilization consent form must be signed at least 30 days before the procedure. We examined whether adequacy of prenatal care mediates the relationship between neighbourhood socioeconomic position and postpartum permanent contraception fulfilment, and examined moderation of relationships by insurance type. Methods: This secondary analysis of a retrospective cohort study examined 3012 Medicaid or privately insured individuals whose contraceptive plan at postpartum discharge was permanent contraception. Path analysis estimated relationships between neighbourhood socioeconomic position (economic hardship and inequality, financial strength and educational attainment) and permanent contraception fulfilment by hospital discharge, directly and indirectly through adequacy of prenatal care. Multigroup testing examined moderation by insurance type. Results: After adjusting for age, parity, weeks of gestation at delivery, mode of delivery, race, ethnicity, marital status and body mass index, having adequate prenatal care predicted achieving desired sterilization at discharge (ß = 0.065, 95% confidence interval [CI]: 0.011, 0.117). Living in neighbourhoods with less economic hardship (indirect effect -0.007, 95% CI: -0.015, -0.001), less financial strength (indirect effect -0.016, 95% CI: -0.030, -0.002) and greater educational attainment (indirect effect 0.012, 95% CI: 0.002, 0.023) predicted adequate prenatal care, in turn predicting achievement of permanent contraception by discharge. Insurance status conditioned some of these relationships. Conclusion: Contact with the healthcare system via prenatal care may be a mechanism by which neighbourhood socioeconomic disadvantage affects permanent contraception fulfilment, particularly for patients with Medicaid. To promote reproductive autonomy and healthcare equity, future inquiry and policy might closely examine how neighbourhood social and economic characteristics interact with Medicaid mandates.

Postpartum contraceptive choice and fulfillment in patients with opioid use disorder.

OBJECTIVE: We examined the differences in postpartum contraception between patients with and without opioid use disorder (OUD). STUDY DESIGN: We conducted a retrospective, single-institution, cohort analysis assessing differences in desired method of postpartum contraception and plan fulfillment. RESULTS: Patients with OUD comprised 200/8654 (2.3%) of our study cohort. After 2:1 matching, method desired (matched odds ratio [mOR] 0.86, 95% confidence interval [CI] 0.60-1.23 for highly vs. moderately effective) and receipt (mOR 0.77, 95% CI 0.53-1.12) of desired method were comparable between groups. CONCLUSION: Patients with and without OUD were similar in their choice and fulfillment of postpartum contraception.

Single-visit insertion of long-acting reversible contraception in a single health system.

OBJECTIVE: To identify patient and practice characteristics associated with single-visit placement of long-acting reversible contraception (LARC) across the University of North Carolina Health system. STUDY DESIGN: We conducted a retrospective observational study using existing electronic health records. We abstracted data from charts of individuals ages 15-50 years who received a LARC device between March 15, 2019, and March 14, 2021. Our primary outcome was whether a patient received LARC at one, or after multiple, outpatient visits. We used descriptive statistics to examine patient, clinician, and practice characteristics. We used bivariate analysis and generalized estimating equation to examine relationships between characteristics and single-visit LARC receipt. RESULTS: Most of the 4599 individuals received care at obstetrics and gynecology clinics (3411/4599; 74%), and received their LARC device in a single visit (3163/4599; 69%). More intrauterine devices (3151) were placed than implants (1448). The adjusted odds of receiving a LARC in a single visit was highest for those who self-paid (aOR (adjusted odds ratio) 1.83, 1.19-2.82) and those who received an implant (aOR 1.25, 1.07-1.46). Patients seen by advanced practice practitioners (aOR 0.67, 0.56-0.80) or by an internal medicine specialty clinician (aOR 0.13, 0.00-0.35) had lower odds of receiving a single-visit LARC compared to those seen by a specialist obstetrician-gynecologist physician. CONCLUSION: Most single-visit LARC placements were performed by clinicians in obstetrician-gynecologist specialty practices. IMPLICATIONS: Among individuals seeking long-acting reversible contraceptives from clinics in a single health system in North Carolina, most received a device at a single visit and most single-visit insertions were done by an obstetrician-gynecologist.

Postpartum Contraceptive Decision-Making of Parous Teens-A Qualitative Study.

STUDY OBJECTIVE: Approximately 25% of teens in the United States will become pregnant before the age of 18, and within 2 years, more than 31% will have a repeat pregnancy. Acknowledging that some adolescents might seek or be ambivalent toward rapid repeat pregnancy, compared with their counterparts, not using a long-acting reversible contraception method increases a teen's risk of another pregnancy in 2 years by more than 35 times. We seek to better understand the influences and factors surrounding adolescent postpartum contraceptive decision-making following the index delivery. DESIGN: We completed a qualitative study via focused, semistructured interviews during an inpatient postpartum course. The interview guide was modeled after those used in other studies of adolescent contraceptive decision-making, beta tested, and developed iteratively. Interviews were completed, transcribed, coded, and analyzed with the assistance of Dedoose. SETTING: The study was conducted at MetroHealth Medical Center in Cleveland, Ohio. PARTICIPANTS: Parous adolescents aged 13-19 RESULTS: We performed 12 interviews prior to reaching theoretical saturation. Themes were identified related to the participants' prior experiences with contraception and prior and current pregnancies. The participants' contraceptive choices were influenced by personal relationships, varying levels of autonomy, misperceptions, and changing contraceptive needs. CONCLUSIONS: We found that adolescents' contraceptive decision-making was influenced by their social networks and community, including their parents and friends. Mothers played a key role as adolescents transitioned to gaining more autonomy over their reproductive decisions. Providers should consistently present adolescents with comprehensive contraceptive options as a component of preventive health care.

Ethical Considerations of Fertility Preservation for Transmasculine and Nonbinary Youth.

An increasing number of young adolescents who identify as transgender or nonbinary are presenting to the health care system for gender affirmation therapy before the full progression of puberty. Gender-affirming therapy may impair future fertility, but options exist for fertility preservation. This perspective reviews these options for transmasculine and nonbinary youth, and explores related ethical considerations. The authors support the right of transgender and nonbinary youth to utilize available reproductive technologies, provide recommendations for treating health professionals, and advocate for increased research efforts and tools to aid patient decision making.

Exploring maternal attitudes towards adolescent contraception: implications for use of LARC.

Introduction Maternal attitudes have been shown to impact adolescent girls' sexual decision making and attitudes towards contraception. Given the potential for maternal influence on adolescent contraceptive use, we undertook an exploratory study of mothers' perceptions of the maternal role in adolescent contraceptive decision making, and maternal perceptions of long acting reversible contraceptives (LARC) for adolescent girls. Materials and methods We utilized a mixed methods study design. Acceptability of contraceptive methods and attitudes towards adolescent contraceptive use were assessed using a paper survey of 162 mothers of girls aged 11-19 years in Cleveland, Ohio, USA. Seven survey participants completed subsequent semi-structured interviews, which were analyzed using grounded theory methodology. Results Pills, condoms and injections were most frequently selected as acceptable by 55.4%, 55.4%, and 51.6% of women, respectively. One or more LARC methods were selected by 16.6% of the women. Of those (94.4%) agreed or strongly agreed that, "It is expected of me to make sure that my daughter knows about birth control methods." Important themes that emerged during interviews were the responsibility mothers felt to help their daughters navigate contraception options, appreciation of the effectiveness of LARC methods and concerns about the use of those methods by teenagers due to the invasiveness. Conclusion Our data suggest that mothers want to be involved and support adolescent decision making about contraceptives. We also found that mothers viewed LARC as less acceptable than other forms of birth control for adolescents and have specific concerns about LARC. These results suggest directions for future work to better characterize the impact of maternal attitudes on adolescent LARC use.

A moving line in the sand: a review of obstetric management surrounding periviability.

Periviable birth poses numerous clinical and ethical challenges for the practicing clinician. We review the data surrounding the administration of corticosteroids for fetal lung maturity, antibiotics in the case of preterm premature rupture of membranes, magnesium sulfate for cerebral palsy prophylaxis, fetal monitoring, and cesarean delivery. The ethical complexities of patient counseling are also reviewed with a recommendation toward shared decision making between patient and physician.