Who is providing contraception care in the United States? An observational study of the contraception workforce.

BACKGROUND: Contraception care is essential to providing comprehensive healthcare; however, little is known nationally about the contraception workforce. Previous research has examined the supply, distribution, and adequacy of the health workforce providing contraception services, but this research has faced a series of data limitations, relying on surveys or focusing on a subset of practitioners and resulting in an incomplete picture of contraception practitioners in the United States. OBJECTIVE: This study aimed to construct a comprehensive database of the contraceptive workforce in the United States that provides the following 6 types of highly effective contraception: intrauterine device, implant, shot (depot medroxyprogesterone acetate), oral contraception, hormonal patch, and vaginal ring. In addition, we aimed to examine the difference in supply, distribution, the types of contraception services offered, and Medicaid participation. STUDY DESIGN: We constructed a national database of contraceptive service providers using multiple data sets: IQVIA prescription claims, preadjudicated medical claims, and the OneKey healthcare provider data set; the National Plan and Provider Enumeration System data set; and the Census Bureau's American Community Survey data on population demographics. All statistical analyses were descriptive, including chi-squared tests for groupwise differences and pairwise post hoc tests with Bonferroni corrections for multiple comparisons. RESULTS: Although 73.1% of obstetrician-gynecologists and 72.6% of nurse-midwives prescribed the pill, patch, or ring, only 51.4% of family medicine physicians, 32.4% of pediatricians, and 19.8% of internal medicine physicians do so. The ratio of all primary care providers prescribing contraception to the female population of reproductive age (ages, 15-44 years) varied substantially across states, with a range of 27.9 providers per 10,000 population in New Jersey to 74.2 providers per 10,000 population in Maine. In addition, there are substantial differences across states for Medicaid acceptance. Of the obstetrician-gynecologists providing contraception, the percentage of providers who prescribe contraception to Medicaid patients ranged from 83.9% (District of Columbia) to 100% (North Dakota); for family medicine physicians, it ranged from 49.7% (Florida) to 91.1% (Massachusetts); and for internal medicine physicians, it ranged from 25.0% (Texas) to 75.9% (Delaware). For in-person contraception, there were large differences in the proportion of providers offering the 3 different contraceptive method types (intrauterine device, implant, and shot) by provider specialty. CONCLUSION: This study found a significant difference in the distribution, types of contraception, and Medicaid participation of the contraception workforce. In addition to obstetrician-gynecologists and nurse-midwives, family medicine physicians, internal medicine physicians, pediatricians, advanced practice nurses, and physician assistants are important contraception providers. However, large gaps remain in the provision of highly effective services such as intrauterine devices and implants. Future research should examine provider characteristics, programs, and policies associated with the provision of different contraception services.

Disparities in Self-Reported Prenatal Counseling: Does Immigrant Status Matter?

Immigrant women face unique barriers to prenatal care access and patient-provider communication. Yet, few prior studies have examined U.S.-born/immigrant differences in the content of care. The purpose of this study was to investigate the roles of immigrant status, English proficiency and race/ethnicity on the receipt of self-reported prenatal counseling using nationally representative data. We used data from the Early Childhood Longitudinal Study-Birth Cohort (N ≈ 8100). We investigated differences in self-reported prenatal counseling by immigrant status, English proficiency, and race/ethnicity using logistic regression. Counseling topics included diet, smoking, drinking, medication use, breastfeeding, baby development and early labor. In additional analyses, we separately examined these relationships among Hispanic, Mexican and Non-Hispanic (NH) Asian women. Neither immigrant status nor self-reported English proficiency was associated with prenatal counseling. However, we found that being interviewed in a language other than English language by ECLS-B surveyors was positively associated with counseling on smoking (OR, 2.599; 95% CI, 1.229-5.495) and fetal development (OR, 2.408; 95% CI, 1.052-5.507) among Asian women. Race/ethnicity was positively associated with counseling, particularly among NH black and Hispanic women. There is little evidence of systematic overall differences in self-reported prenatal counseling between U.S.-born and immigrant mothers. Future research should investigate disparities in pregnancy-related knowledge among racial/ethnic subgroups.

Association of Primary Care Physicians' Individual- and Community-Level Characteristics With Contraceptive Service Provision to Medicaid Beneficiaries.

Importance: Little is known about primary care physicians who provide contraceptive services to Medicaid beneficiaries. Evaluating this workforce may help explain barriers to accessing these services since contraceptive care access is critical for Medicaid beneficiaries' health. Objective: To describe the primary care physician workforce that provides contraceptive services to Medicaid beneficiaries and explore the factors associated with their Medicaid contraceptive service provision. Design, Setting, and Participants: This cross-sectional study, conducted from August 1 to October 10, 2022, used data from the Transformed Medicaid Statistical Information System from 2016 for primary care physicians from 4 specialties (family medicine, internal medicine, obstetrics and gynecology [OBGYN], and pediatrics). Main Outcomes and Measures: The main outcomes were providing intrauterine devices (IUDs) or contraceptive implants to at least 1 Medicaid beneficiary, prescribing hormonal birth control methods (including a pill, patch, or ring) to at least 1 Medicaid beneficiary, the total number of Medicaid beneficiaries provided IUDs or implants, and the total number Medicaid beneficiaries prescribed hormonal birth control methods in 2016. Physician- and community-level factors associated with contraceptive care provision were assessed using multivariate regression methods. Results: In the sample of 251 017 physicians (54% male; mean [SD] age, 49.17 [12.58] years), 28% were international medical graduates (IMGs) and 70% practiced in a state that had expanded Medicaid in 2016. Of the total physicians, 48% prescribed hormonal birth control methods while 10% provided IUDs or implants. For OBGYN physicians, compared with physicians younger than 35 years, being aged 35 to 44 years (odds ratio [OR], 3.51; 95% CI, 2.93-4.21), 45 to 54 years (OR, 3.01; 95% CI, 2.43-3.72), or 55 to 64 years (OR, 2.27; 95% CI, 1.82-2.83) was associated with higher odds of providing IUDs and implants. However, among family medicine physicians, age groups associated with lower odds of providing IUDs or implants were 45 to 54 years (OR, 0.66; 95% CI, 0.55-0.80), 55 to 64 years (OR, 0.51; 95% CI, 0.39-0.65), and 65 years or older (OR, 0.29; 95% CI, 0.19-0.44). Except for those specializing in OBGYN, being an IMG was associated with lower odds of providing hormonal contraceptive service (family medicine IMGs: OR, 0.80 [95% CI, 0.73-0.88]; internal medicine IMGs: OR, 0.85 [95% CI, 0.77-0.93]; and pediatric IMGs: OR, 0.85 [95% CI, 0.78-0.93]). Practicing in a state that expanded Medicaid by 2016 was associated with higher odds of prescribing hormonal contraception for family medicine (OR 1.50; 95% CI, 1.06-2.12) and internal medicine (OR, 1.71; 95% CI, 1.18-2.48) physicians but not for physicians from other specialties. Conclusions and Relevance: In this cross-sectional study of primary care physicians, physician- and community-level factors, such as specialty, age, and the Medicaid expansion status of their state, were significantly associated with how they provided contraceptive services to Medicaid beneficiaries. However, the existence of associations varied across clinical specialties. Ensuring access to contraception among Medicaid beneficiaries may therefore require policy and program approaches tailored for different physician types.

Training in Residency and Provision of Reproductive Health Services Among Family Medicine Physicians.

Importance: Contraception and abortion services are essential health care, and family medicine (FM) physicians are an important part of the workforce providing this care. Residency could inform the reproductive health services FM physicians provide. Objective: To determine which residency training factors are associated with FM physicians' provision of reproductive health services to Medicaid beneficiaries. Design, Setting, and Participants: This cross-sectional, population-based observational study of inpatient and outpatient FM physicians who completed residency between 2008 and 2018 and treated at least 1 Medicaid beneficiary in 2019 was conducted from November 2022 to March 2023. The study used 2019 American Medical Association Masterfile and Historical Residency file, as well as the 2019 Transformed Medicaid Statistical Information System claims. Exposures: Residency training in community-based or reproductive health-focused programs. Main Outcomes and Measures: The outcomes were providing the following to at least 1 Medicaid beneficiary in 2019: prescription contraception (pill, patch, and/or ring), intrauterine device (IUD) and/or contraceptive implant, and dilation and curettage (D&C). Odds of providing each outcome were measured using correlated random-effects regression models adjusted for physician, residency program, and county characteristics. Results: In the sample of 21 904 FM physician graduates from 410 FM residency programs, 12 307 were female (56.3%). More than half prescribed contraception to Medicaid beneficiaries (13 373 physicians [61.1%]), with lower proportions providing IUD or implant (4059 physicians [18.5%]) and D&C (152 physicians [.7%]). FM physicians who graduated from a Reproductive Health Education in Family Medicine program, which fully integrates family planning into residency training, had significantly greater odds of providing prescription contraception (odds ratio [OR], 1.23; 95% CI, 1.07-1.42), IUD or implant (OR, 1.79; 95% CI, 1.28-2.48), and D&C (OR, 3.61; 95% CI, 2.02-6.44). Physicians who completed residency at a Teaching Health Center, which emphasizes community-based care, had higher odds of providing an IUD or implant (OR, 1.51; 95% CI, 1.19-1.91). Conclusions and Relevance: In this cross-sectional study of FM physicians providing Medicaid service, characteristics of residency training including community-based care and integration of family planning training are associated with greater odds of providing reproductive health services. With growing reproductive health policy restrictions, providing adequate training in reproductive health is critical to maintaining access to care, especially for underserved populations.

Primary Care Provider Medicaid Participation Across the United States, 2016.

PURPOSE: To understand primary care provider participation in Medicaid programs across states and provider specialties and professions. METHODS: We examined the 2016 Medicaid claims data across 45 states and territories from the Transformed Medicaid Statistical Information System (T-MSIS). RESULTS: Of the 616,182 primary care providers we identified, 111,152 (18.0%) saw no Medicaid patients, 88,723 (14.4%) providers saw one to 10 Medicaid patients, 163,806 (26.6%) saw 11 to 100 Medicaid patients, and 252,501 (41.0%) saw more than 100 Medicaid patients in 2016. The proportion of providers who saw more than 100 Medicaid patients ranged from 22.9% in Virginia to 56.1% in New Mexico. Medicaid participation also differed by specialty, from 78.4% among pediatricians to 61.2% among nurse practitioners. This study lays the foundations for using T-MSIS data to identify communities at the highest risk for access barriers and support targeted policy responses.

Estimating the differences in Caesarean section (C-section) rates between public and privately insured mothers in Florida: A decomposition approach.

BACKGROUND: Caesarean section (C-sections) is a medically critical and often life-saving procedure for prevention of childbirth complications. However, there are reports of its overuse, especially in women covered by private insurance as compared to public insurance. This study evaluates the difference in C-Section rates among nulliparous women in Florida hospitals across insurance groups and quantifies the contribution of maternal and hospital factors in explaining the difference in rates. METHODS: We used Florida's inpatient data provided by the Florida Agency for HealthCare Administration (FLAHCA) and focused on low-risk births that occurred between January 1, 2010, and September 30, 2015. A Fairlie decomposition method was performed on cross-sectional data to decompose the difference in C-Section rates between insurance groups into the proportion explained versus unexplained by the differences in observable maternal and hospital factors. RESULTS: Of the 386,612 NTSV low-risk births, 72,984 were delivered via C-Section (18.87%). Higher prevalence of C-section at maternal level was associated with diabetes, hypertension, and the expectant mother being over 35 years old. Higher prevalence of C-section at the hospital level was associated with lower occupancy rate, presence of neonatal ICU (NICU) unit and higher obstetrics care level in the hospital. Private insurance coverage in expectant mothers is associated with C-section rates that were 4.4 percentage points higher as compared to that of public insurance. Just over 33.7% of the 4.4 percentage point difference in C-section rates between the two insurance groups can be accounted for by maternal and hospital factors. CONCLUSIONS: The study identifies that the prevalence of C-sections in expectant mothers covered by private insurance is higher compared to mothers covered by public insurance. Although, majority of the difference in C-Section rates across insurance groups remains unexplained (around 66.3%), the main contributor that explains the other 33.7% is advancing maternal age and socioeconomic status of the expectant mother. Further investigation to explore additional factors that explain the difference needs to be done if United States wants to target specific policies to lower overall C-Section rate.

Pregnancy-related weight among immigrant and US-born mothers: The role of nativity, maternal duration of residence, and age at arrival.

OBJECTIVES: The goals of this study were to examine the associations between nativity and pregnancy-related weight and to assess the associations between maternal duration of residence and age at arrival in the United States on pregnancy-related weight among immigrants. METHODS: Using logistic regression and data from the Early Childhood Longitudinal Study-Birth Cohort, we assessed differences in preconception weight and gestational weight gain between US-born and immigrant women (N = 7000). We then analyzed differences in both outcomes by duration of residence among immigrants (n = 1850) and examined whether the identified relationships varied by age at arrival in the United States. RESULTS: Compared to US-born mothers, immigrants were less likely to be classified as obese prior to pregnancy (odds ratio 0.435, 95% confidence interval, 0.321-0.590) or experience excessive gestational weight gain (odds ratio 0.757, 95% confidence interval, 0.614-0.978). Among the immigrant sub-sample, living in the United States for 10-15 years (odds ratio 2.737, 95% confidence interval, 1.459-5.134) or 16+ years was positively associated with both preconception obesity (odds ratio 2.918, 95% confidence interval, 1.322-6.439) and excessive gestational weight gain (odds ratio 1.683, 95% confidence interval, 1.012-2.797, 16+ years only). There was some evidence that the duration of residence was positively associated with preconception obesity, but only among women who had moved to the United States at age 18 years and older. CONCLUSION: In sum, while immigrants are less likely than US-born mothers to experience preconception obesity or excessive gestational weight gain, these outcomes vary among the former group by duration of US residence.

Pregnancy-Related Weight and Postpartum Depressive Symptoms: Do the Relationships Differ by Race/Ethnicity?

Background: There are significant racial/ethnic disparities in the prevalence of postpartum depression. Prior research in the general population suggests that weight status is related to depression and that this relationship varies by race/ethnicity. However, few studies have investigated whether race/ethnicity moderates the relationship between pregnancy-related weight and postpartum depressive symptoms (PPDS). The objective of this study is to examine the relationship between pregnancy-related weight and maternal PPDS overall and by race/ethnicity. Materials and Methods: This study used data from the Early Childhood Longitudinal Study-Birth Cohort (n ≈ 6950). Ordinary least-squares and logistic regression was used to examine whether pregnancy-related weight, including preconception weight status and gestational weight gain (GWG), was associated with PPDS measured using the Center for Epidemiologic Studies-Depression Scale (CES-D). Stratified analyses were used to assess whether these relationships varied by race/ethnicity. Results: Preconception obesity (body mass index [BMI] ≥30 kg/m2) was associated with higher levels of PPDS (ß = 0.601, 95% confidence interval [CI], 0.149-1.053). GWG adequacy was not associated with PPDS. Among non-Hispanic (NH) whites, preconception obesity was positively associated with PPDS (ß = 1.016, 95% CI, 0.448-1.584). In contrast, among Hispanics, preconception overweight (25 kg/m2 ≤ BMI <30 kg/m2) was associated with lower levels of PPDS (ß = -0.887, 95% CI, -1.580 to -0.195). There were no statistically significant relationships between pregnancy-related weight and PPDS among NH black or Asian women, but both groups were significantly more likely than NH whites to report PPDS. Conclusion: Whether and how pregnancy-related weight is associated with PPDS varies by race/ethnicity. Addressing preconception weight could help reduce overall levels of PPDS among NH whites but would likely fail to mitigate racial/ethnic disparities in postpartum mental health.

Positional scanning for peptide secondary structure by systematic solid-phase synthesis of amino lactam peptides.

Incorporation of amino lactams into biologically active peptides has been commonly used to restrict conformational mobility, enhance selectivity, and increase potency. A solid-phase method using a Fmoc-protection strategy has been developed for the systematic synthesis of peptides containing configurationally defined alpha- and beta-amino gamma-lactams. N-Alkylation of N-silyl peptides with five- and six-member cyclic sulfamidates 9 and 8 minimized bis-alkylation and provided N-alkyl peptides, which underwent lactam annulation under microwave heating. Employing this solid-phase protocol on the growth hormone secretagogue GHRP-6, as well as on the allosteric modulator of the IL-1 receptor 101.10, has furnished 16 lactam derivatives and validated the effectiveness of this approach on peptides bearing aliphatic, aromatic, branched, charged, and heteroatomic side chains. The binding affinity IC(50) values of the GHRP-6 lactam analogues on both the GHS-R1a and CD36 receptors are reported as well as inhibition of thymocyte proliferation measurements for the 101.10 lactam analogues. In these cases, lactam analogues were prepared exhibiting similar or improved properties compared with the parent peptide. Considering the potential for amino lactams to induce peptide turn conformations, the effective method described herein for their supported construction on growing peptides, and for the systematical amino lactam scan of peptides, has proven useful for the rapid identification of the secondary structure necessary for peptide biological activity.

Contraception Usage and Workforce Trends Through 2022.

This cross-sectional study uses a national data set of medical prescription claims to examine contraception service and workforce changes from January 2019 through December 2022 in the US.

Asymmetric synthesis of both the enantiomers of trans-3-hydroxypipecolic acid.

Both the enantiomers of trans-3-hydroxypipecolic acid have been synthesized employing the Sharpless asymmetric dihydroxylation and epoxidation as the key steps starting from a commercially available starting material 1,4-butanediol.