Fulfillment of Permanent Contraception among Patients with Cesarean Delivery in a Multi-Site Cohort.

OBJECTIVES: This study aimed to assess the association between insurance type and permanent contraception fulfillment among those with cesarean deliveries. Additionally, we sought to examine modification by the scheduled status of the cesarean. STUDY DESIGN: We used data from a multi-site cohort study of patients who delivered in 2018-2019 at Northwestern Memorial Hospital in Illinois, MetroHealth Medical System in Ohio, or University of Alabama at Birmingham in Alabama. All patients had permanent contraception as their contraceptive plan in their medical chart during delivery hospitalization. We used logistic regression to model the association between insurance type, scheduled status of cesarean and permanent contraception fulfillment by hospital discharge. The scheduled status of cesarean delivery was examined as an effect modifier. RESULTS: Compared to patients with private insurance, those with Medicaid were less likely to have their desired permanent contraception procedure fulfilled by hospital discharge (89.3% vs. 96.8%, p < 0.001). After adjusting for covariates, patients with Medicaid had a lower odds of permanent contraception fulfillment by hospital discharge (OR: 0.41; 95% CI: 0.21, 0.77). This association was stronger among those who had unscheduled cesarean deliveries (OR: 0.29; 95% CI: 0.12, 0.74) than those with scheduled cesarean deliveries (OR: 0.77; 95% CI: 0.32, 1.88). CONCLUSIONS FOR PRACTICE: Compared to patients with private insurance undergoing a cesarean delivery, those with Medicaid insurance were less likely to have their desired permanent contraception fulfilled. Physicians and hospitals must examine their practices surrounding Medicaid forms to ensure that patients have valid consent forms available at the time of delivery.

Documentation of prenatal contraceptive counseling and fulfillment of permanent contraception: a retrospective cohort study.

BACKGROUND: Barriers exist for the provision of surgery for permanent contraception in the postpartum period. Prenatal counseling has been associated with increased rates of fulfillment of desired postpartum contraception in general, although it is unclear if there is impact on permanent contraception specifically. Thus, we aimed to investigate the association between initial timing for prenatal documentation of a contraceptive plan for permanent contraception and fulfillment of postpartum contraception for those receiving counseling. METHODS: This is a planned secondary analysis of a multi-site cohort study of patients with documented desire for permanent contraception at the time of delivery at four hospitals located in Alabama, California, Illinois, and Ohio over a two-year study period. Our primary exposure was initial timing of documented plan for contraception (first, second, or third trimester, or during delivery hospitalization). We used univariate and multivariable logistic regression to analyze fulfillment of permanent contraception before hospital discharge, within 42 days of delivery, and within 365 days of delivery between patients with a documented plan for permanent contraception in the first or second trimester compared to the third trimester. Covariates included insurance status, age, parity, gestational age, mode of delivery, adequacy of prenatal care, race, ethnicity, marital status, and body mass index. RESULTS: Of the 3103 patients with a documented expressed desire for permanent contraception at the time of delivery, 2083 (69.1%) had a documented plan for postpartum permanent contraception prenatally. After adjusting for covariates, patients with initial documented plan for permanent contraception in the first or second trimester had a higher odds of fulfillment by discharge (aOR 1.57, 95% C.I 1.24-2.00), 42 days (aOR 1.51, 95% C.I 1.20-1.91), and 365 days (aOR 1.40, 95% C.I 1.11-1.75), compared to patients who had their first documented plan in the third trimester. CONCLUSIONS: Patients who had a documented prenatal plan for permanent contraception in trimester one and two experienced higher likelihood of permanent contraception fulfillment compared to those with documentation in trimester three. Given the barriers to accessing permanent contraception, it is imperative that comprehensive, patient-centered counseling and documentation regarding future reproductive goals begin early prenatally.

Permanent contraception is a highly desired form of postpartum contraception in the United States, however there are several barriers to accessing it. In this paper, we investigate whether the timing of when a patient has a documented plan for postpartum contraception has an impact on if they achieve postpartum contraception. This is a cohort study from four hospitals in Illinois, Ohio, California, and Alabama for patients with a desire for postpartum permanent contraception documented in their medical record. We specifically investigated the trimester (first, second, or third) where a patient had a plan for permanent contraception first documented. We then used univariate and multivariate models to determine the relationship between the timing of a plan for permanent contraception and if a patient achieved the procedure at three time-points: hospital discharge, 42-days, and 365-days. Our findings showed that of the 3103 patients in our cohort, only 69.1% of them had a documented plan for postpartum contraception at any point before going to the hospital for their delivery admission. We additionally found that patients who had a documented plan for permanent contraception in the first or second trimester had a higher odds of receiving their postpartum contraception procedure compared to people who had their first documented plan in the third trimester. This showed us the importance of earlier counseling regarding contraception for pregnant patients. There are many barriers to accessing postpartum contraception, so having patient focused counseling about future goals around reproductive health early on in pregnancy is critical.

Ethical Issues in Providing and Promoting Contraception to Women with Opioid Use Disorder.

Women with opioid use disorder (OUD) face unique challenges meeting their reproductive goals. Because the rate of unintended pregnancy in this population is almost 80 percent, there has been a push to increase the use of contraceptives among reproductive-aged women with OUD.1 The patient-level ethical issues of such initiatives, however, are often overlooked. This review discusses the ethical issues in two realms: obtaining contraception when it is desired and avoiding contraceptive coercion when contraception is not desired. It is important that access to reproductive education and care be improved to ensure autonomous decision making by women with OUD. It is also necessary to be mindful of the history of oppressive and coercive contraception and sterilization policies in the United States. These policies have left a legacy of mistrust and continue to be manifested in the form of more subtly oppressive policies in contemporary medical practice. Such policies point to the ongoing stigmatization of, and implicit biases held against, women with OUD. Based on these ethical issues, solutions are suggested at the clinical, systemic, and societal levels.

Association of race and ethnicity with postpartum contraceptive method choice, receipt, and subsequent pregnancy.

BACKGROUND: We sought to assess racial/ethnic differences in choice of postpartum contraceptive method after accounting for clinical and demographic correlates of contraceptive use. METHODS: This is a secondary analysis of a single-center retrospective cohort study examining postpartum women from 2012 to 2014. We determined the association between self-identified race/ethnicity and desired postpartum contraception, receipt, time to receipt, postpartum visit attendance, and subsequent pregnancy within 365 days of delivery. RESULTS: Of the 8649 deliveries in this study, 46% were by Black women, 36% White women, 12% Hispanic, and 6% by women of other races. Compared with White women, Black and Hispanic women were more likely to have a postpartum contraception plan for all methods. After multivariable analysis, Hispanic women (relative to White women) were less likely to receive their chosen method (odds ratio [OR] 0.74, 95% confidence interval [CI] 0.64-0.87). Women of races other than Black or Hispanic were less likely to experience a delay in receipt of their desired highly-effective method compared to White women (hazard ratio [HR] = 0.70, 95% CI 0.52-0.94). There were no differences between racial/ethnic groups in terms of postpartum visit adherence. Black women were more likely to be diagnosed with a subsequent pregnancy compared to White women (OR 1.17, 95% CI 1.04-1.32). CONCLUSION: Racial/ethnic variation in postpartum contraceptive outcomes persists after accounting for clinical and demographic differences. While intrinsic patient-level differences in contraceptive preferences should be better understood and respected, clinicians should take steps to ensure that the observed differences in postpartum contraceptive plan methods between racial/ethnic groups are not due to biased counseling.

Ethical challenges for women's healthcare highlighted by the COVID-19 pandemic.

Healthcare policies developed during the COVID-19 pandemic to safeguard community health have the potential to disadvantage women in three areas. First, protocols for deferral of elective surgery may assign a lower priority to important reproductive outcomes. Second, policies regarding the prevention and treatment of COVID-19 may not capture the complexity of the considerations related to pregnancy. Third, policies formulated to reduce infectious exposure inadvertently may increase disparities in maternal health outcomes and rates of violence towards women. In this commentary, we outline these challenges unique to women's healthcare in a pandemic, provide preliminary recommendations and identify areas for further exploration and refinement of policy.

Changes in Rates of Inpatient Postpartum Long-Acting Reversible Contraception and Sterilization in the USA, 2012-2016.

OBJECTIVES: To examine recent rates of long-acting and permanent methods (LAPM) of contraception use during delivery hospitalization and correlates of their use. METHODS: A retrospective cohort study utilizing the 2012-2016 National Inpatient Sample of hospitalizations in the United States of America. The International Classification of Diseases, 9th and 10th Revision, Clinical Modification codes were used to identify deliveries, inpatient long-acting reversible contraception (IPP LARC), and postpartum tubal ligation (PPTL). We conducted univariable and multivariable logistic regression to examine associations between demographic, clinical, hospital and geographical characteristics with likelihood of LAPM including IPP LARC and PPTL. RESULTS: Our sample included 3,642,328 unweighted deliveries. The rate of IPP LARC increased from 34.6 to 54.9 per 10,000 deliveries (58.7%), while the rate of PPTL utilization decreased from 719.5 to 671.8 per 10,000 deliveries (6.6%) over the study period. In multivariable analysis of LAPM utilization versus neither, cesarean delivery (aOR 7.25, 95% CI 7.08-7.43) was associated with greater utilization. Native American (aOR 4.01, 95% CI 2.91-5.53) race was associated with increased use of IPP LARC compared to a non-long-acting method of contraception. Age between 18 and 29 years (aOR 6.21, 95% CI 5.42-7.11) was associated with greater use of IPP LARC versus PPTL. Delivering in a rural hospital ((aOR 0.09, 95% CI 0.06-0.12) and cesarean delivery (aOR 0.09, 95% CI 0.06-0.12) were associated with greater use PPTL versus IPP LARC. CONCLUSIONS: The IPP LARC rate remains at less than 10% the PPTL rates in our study timeframe. The demonstrated variation in uptake of highly effective methods of contraception inpatient after delivery offer possible opportunities for better understanding and improvement in access.

Association between neighborhood disadvantage and fulfillment of desired postpartum sterilization.

BACKGROUND: Adequacy of prenatal care is associated with fulfillment of postpartum sterilization requests, though it is unclear whether this relationship is indicative of broader social and structural determinants of health or reflects the mandatory Medicaid waiting period required before sterilization can occur. We evaluated the relationship between neighborhood disadvantage (operationalized by the Area Deprivation Index; ADI) and the likelihood of undergoing postpartum sterilization. METHODS: Secondary analysis of a single-center retrospective cohort study examining 8654 postpartum patients from 2012 to 2014, of whom 1332 (15.4%) desired postpartum sterilization (as abstracted from the medical record at time of delivery hospitalization discharge) and for whom ADI could be calculated via geocoding their home address. We determined the association between ADI and sterilization completion, postpartum visit attendance, and subsequent pregnancy within 365 days of delivery via logistic regression and time to sterilization via Cox proportional hazards regression. RESULTS: Of the 1332 patients included in the analysis, patients living in more disadvantaged neighborhoods were more likely to be younger, more parous, delivered vaginally, Black, unmarried, not college educated, and insured via Medicaid. Compared to patients living in less disadvantaged areas, patients living in more disadvantaged areas were less likely to obtain sterilization (44.8% vs. 53.5%, OR 0.84, 95% CI 0.75-0.93), experienced greater delays in the time to sterilization (HR 1.23, 95% CI 1.06-1.44), were less likely to attend postpartum care (58.9% vs 68.9%, OR 0.86, CI 0.79-0.93), and were more likely to have a subsequent pregnancy within a year of delivery (15.1% vs 10.4%, OR 1.56, 95% CI 1.10-1.94). In insurance-stratified analysis, for patients with Medicaid, but not private insurance, as neighborhood disadvantage increased, the rate of postpartum sterilization decreased. The rate of subsequent pregnancy was positively associated with neighborhood disadvantage for both Medicaid as well as privately insured patients. CONCLUSION: Living in an area with increased neighborhood disadvantage is associated with worse outcomes in terms of desired postpartum sterilization, especially for patients with Medicaid insurance. While revising the Medicaid sterilization policy is important, addressing social determinants of health may also play a powerful role in reducing inequities in fulfillment of postpartum sterilization.

Ethical Implications of Donor Type for Uterus Transplantation: Why We Should Remain Wary of Using Living Donors.

Over the last few years, research teams have made significant advancements in treating absolute uterine factor infertility through uterus transplantation, culminating in the birth of the first US baby born from a uterus transplant in November 2017. However, studies have differed on the choice of either deceased or living donors, with some centers even exploring both methods. As researchers continue to investigate the medical feasibility of these approaches, it is also important for the medical community to consider how deceased and living uterus donation differ ethically. We argue that if living and deceased donation demonstrate equivalent clinical efficacy and the deceased donor pool is sufficient, living uterus donation should be reevaluated and may no longer be ethically justifiable.

Feasibility of an ethics and professionalism curriculum for faculty in obstetrics and gynecology: a pilot study.

OBJECTIVE: There have been increased efforts to implement medical ethics curricula at the student and resident levels; however, practising physicians are often left unconsidered. Therefore, we sought to pilot an ethics and professionalism curriculum for faculty in obstetrics and gynaecology to remedy gaps in the formal, informal and hidden curriculum in medical education. METHODS: An ethics curriculum was developed for faculty within the Department of Obstetrics and Gynaecology at a tertiary care, academic hospital. During the one-time, 4-hour, mandatory in-person session, the participants voluntarily completed the Oldenburg Burnout Inventory, Handoff Clinical Evaluation Exercise, University of Missouri-Kansas City School of Medicine and overall course evaluation. Patient satisfaction survey scores in both the hospital and ambulatory settings were compared before and after the curriculum. RESULTS: Twenty-eight faculty members attended the curriculum. Overall, respondents reported less burnout and performed at the same level or better in terms of patient handoff than the original studies validating the instruments. Faculty rated the professionalism behaviours as well as teaching of professionalism much lower at our institution than the validation study. There was no change in patient satisfaction after the curriculum. However, overall, the course was well received as meeting its objectives, being beneficial and providing new tools to assess professionalism. CONCLUSION: This pilot study suggests that an ethics curriculum can be developed for practising physicians that is mindful of pragmatic concerns while still meeting its objectives. Further study is needed regarding long term and objective improvements in ethics knowledge, impact on the education of trainees and improvement in the care of patients as a result of a formal curriculum for faculty.

Consenting to invasive contraceptives: an ethical analysis of adolescent decision-making authority for long-acting reversible contraception.

Since USA constitutional precedent established in 1976, adolescents have increasingly been afforded the right to access contraception without first obtaining parental consent or authorisation. There is general agreement this ethically permissible. However, long-acting reversible contraception (LARC) methods have only recently been prescribed to the adolescent population. They are currently the most effective forms of contraception available and have high compliance and satisfaction rates. Yet unlike other contraceptives, LARCs are associated with special procedural risks because they must be inserted and removed by trained healthcare providers. It is unclear whether the unique invasive nature of LARC changes the traditional ethical calculus of permitting adolescent decision-making in the realm of contraception. To answer this question, we review the risk-benefit profile of adolescent LARC use. Traditional justifications for permitting adolescent contraception decision-making authority are then considered in the context of LARCs. Finally, analogous reasoning is used to evaluate potential differences between permitting adolescents to consent for LARC procedures versus for emergency and pregnancy termination procedures. Ultimately, we argue that the invasive nature of LARCs does not override adolescents' unique and compelling need for safe and effective forms of contraception. In fact, LARCs may oftentimes be in the best interest of adolescent patients who wish to prevent unintended pregnancy. We advocate for the specific enumeration of adolescents' ability to consent to both LARC insertion and removal procedures within state policies. Given the provider-dependent nature of LARCs and the stigma regarding adolescent sexuality, special political and procedural safeguards to protect adolescent autonomy are warranted.

Uterus Transplantation: The Ethics of Using Deceased Versus Living Donors.

Research teams have made considerable progress in treating absolute uterine factor infertility through uterus transplantation, though studies have differed on the choice of either deceased or living donors. While researchers continue to analyze the medical feasibility of both approaches, little attention has been paid to the ethics of using deceased versus living donors as well as the protections that must be in place for each. Both types of uterus donation also pose unique regulatory challenges, including how to allocate donated organs; whether the donor / donor's family has any rights to the uterus and resulting child; how to manage contact between the donor / donor's family, recipient, and resulting child; and how to track outcomes moving forward.

Prevalence and County-Level Distribution of Births in Catholic Hospitals in the US in 2020.

This study uses American Hospital Association data to examine the volume and distribution of births in Catholic US hospitals and quantify county-level patterns of Catholic and non-Catholic hospital births.

Refusal of Vaccination: A Test to Balance Societal and Individual Interests.

While all states in the United States require certain vaccinations for school attendance, all but three allow for religious exemptions to receiving such vaccinations, and 18 allow for exemptions on the basis of other deeply held personal beliefs. The rights of parents to raise children as they see fit may conflict with the duty of the government and society to protect the welfare of children. In the U.S., these conflicts have not been settled in a uniform and consistent manner. We apply a test that provides a concrete and formal rubric to evaluate such conflicts. For some vaccinations, based on the individual medical characteristics of the disease and the risks of being unvaccinated, the test would suggest that permitting conscientious exemptions is ethical. However, for vaccinations protecting against other diseases that are more severe or easily transmitted, the test would suggest that the federal government may ethically impose laws that deny such exemptions.

Improving Rates of Post-Essure Hysterosalpingography in an Urban Population Using Electronic Tracking Reminders.

STUDY OBJECTIVE: To demonstrate the efficacy of electronic reminders for follow-up hysterosalpingography (HSG) after Essure hysteroscopic sterilization in an urban tertiary care hospital obstetrics and gynecology practice. DESIGN: Retrospective cohort study (Canadian Task Force classification II-3). SETTING: Obstetrics and gynecology practice at a university-affiliated urban tertiary care teaching hospital. PATIENTS: Two hundred and fifty patients who underwent Essure hysteroscopic sterilization between June 2011 and July 2014. INTERVENTION: Implementation of electronic reminders for the office staff. MEASUREMENTS AND MAIN RESULTS: Two hundred and fifty of 259 patients (96.5%) underwent Essure hysteroscopic sterilization and successful placement of coils into bilateral Fallopian tubes. Among these 250 patients, 135 (54%) returned for HSG at 3 months post-Essure as advised at the time of procedure. The use of electronic reminders prompted another 45 patients (18%) to return for HSG, improving the total post-Essure follow-up rate to 72%. CONCLUSION: Electronic reminders for the office staff of an urban tertiary care hospital's obstetrics and gynecology practice is an effective method for improving the rate of post-Essure HSG.

Punishment of Minor Female Genital Ritual Procedures: Is the Perfect the Enemy of the Good?

Female genital alteration (FGA) is any cutting, removal or destruction of any part of the external female genitalia. Various FGA practices are common throughout the world. While most frequent in Africa and Asia, transglobal migration has brought ritual FGA to Western nations. All forms of FGA are generally considered undesirable for medical and ethical reasons when performed on minors. One ritual FGA procedure is the vulvar nick (VN). This is a small laceration to the vulva that does not cause morphological changes. Besides being performed as a primary ritual procedure it has been proposed as a substitute for more extensive forms of FGA. Measures advocated or taken to reduce the burden of FGA can be punitive or non-punitive. Even if it is unethical to perform VN, we argue that it also is unethical to attempt to suppress it through punishment. First, punishment of VN is likely to cause more harm than good overall, even to those ostensibly being protected. Second, punishment is likely to exceed legitimate retributive ends. We do not argue in favor of performing VN. Rather, we argue that non-punitive strategies such as education and harm reduction should be employed.

Triggers, bundles, protocols, and checklists--what every maternal care provider needs to know.

The rise in maternal morbidity and mortality has resulted in national and international attention at optimally organizing systems and teams for pregnancy care. Given that maternal morbidity and mortality can occur unpredictably in any obstetric setting, specialists in general obstetrics and gynecology along with other primary maternal care providers should be integrally involved in efforts to improve the safety of obstetric care delivery. Quality improvement initiatives remain vital to meeting this goal. The evidence-based utilization of triggers, bundles, protocols, and checklists can aid in timely diagnosis and treatment to prevent or limit the severity of morbidity as well as facilitate interdisciplinary, patient-centered care. The purpose of this document is to summarize the pertinent elements from this forum to assist primary maternal care providers in their utilization and implementation of these safety tools.

Female genital alteration: a compromise solution.

Despite 30 years of advocacy, the prevalence of non-therapeutic female genital alteration (FGA) in minors is stable in many countries. Educational efforts have minimally changed the prevalence of this procedure in regions where it has been widely practiced. In order to better protect female children from the serious and long-term harms of some types of non-therapeutic FGA, we must adopt a more nuanced position that acknowledges a wide spectrum of procedures that alter female genitalia. We offer a revised categorisation for non-therapeutic FGA that groups procedures by effect and not by process. Acceptance of de minimis procedures that generally do not carry long-term medical risks is culturally sensitive, does not discriminate on the basis of gender, and does not violate human rights. More morbid procedures should not be performed. However, accepting de minimis non-therapeutic f FGA procedures enhances the effort of compassionate practitioners searching for a compromise position that respects cultural differences but protects the health of their patients.