Parenthood and Medical Training: Challenges and Experiences of Physician Moms in the US.

Phenomenon: Balancing the demands of medical training and parenthood is challenging. We explored perceptions of programmatic support, parental leave, breastfeeding, and self-reported biggest challenges among a large cohort of physician mothers in a variety of medical specialties and across the stage of training when they had their first child. Our goal was to inform strategies to help improve the physician parent experience. Approach: This cross-sectional, observational survey study was performed using a convenience sample from an online physician-mom support group from January to February 2018. Descriptive statistics and bivariate analyses were used to report results and examine relationships between career stage at first child and outcome variables. Responses to the open-ended question, "What is your biggest challenge as a physician mom?" were qualitatively analyzed. Findings: The survey received 896 complete responses. The most common specialties were obstetrics and gynecology (25.3%), pediatrics (19.9%), internal medicine or medicine/pediatrics (17.1%), and family medicine (10.2%). The majority of participants (63.9%) had their first child during medical training, including medical school (14.3%), residency (35.8%) or fellowship (13.6%). Medical students were less likely to perceive programmatic support than residents or fellows (44.1% vs. 63.1% vs. 62.3%, respectively), and only 19.9% of participants who became parents during medical training reported having a clear and adequate parental leave policy. Nearly 70% of participants breastfed for six months or more, with no statistical differences across career stage. Most participants (57.6%) delayed child-bearing for one or more reasons, with 32.3% delaying to complete training. The most common codes applied to responses for 'biggest challenges as a physician mom' were insufficient time, lack of work-life balance, missing out, and over-expectation. Insights: Physician mothers, particularly those who had their first child during training, continue to struggle with support from training programs, finding work-life balance, and feelings of inadequacy. Interventions such as clear and adequate leave policies, program-sponsored or onsite childcare and improved programmatic support of breastfeeding and pumping may help to ameliorate the challenges described by our participants.

Experiences of Perceived Gender-based Discrimination Among Women Veterans: Data From the ECUUN Study.

BACKGROUND: Experiences of discrimination are associated with poor health behaviors and outcomes. Understanding discrimination in health care informs interventions to improve health care experiences. OBJECTIVE: Describe the prevalence of, and variables associated with, perceived gender-based discrimination in the Veterans Affairs (VA) Healthcare System among women Veterans. DESIGN: A cross-sectional, telephone-based survey of a random national sample of young female Veterans. PARTICIPANTS: Female VA primary care patients aged 18-45 years. MAIN MEASURES: The primary outcome was perceived gender-based discrimination in VA health care. Logistic and linear regression models were used to determine associations between any perceived discrimination and cumulative perceived discrimination with patient and health service characteristics. KEY RESULTS: Among 2294 women Veterans, 33.7% perceived gender-based discrimination in VA. Perceiving gender-based discrimination was associated with medical illness [adjusted odds ratio (aOR)=1.67, 95% confidence interval (CI)=1.34, 2.08], mental illness (aOR=2.06, 95% CI=1.57, 2.69), and military sexual trauma (aOR=2.65, 95% CI=2.11, 3.32). Receiving most health care from the same VA provider (aOR=0.73, 95% CI=0.57, 0.94) and receiving care at a VA site with a women's health clinic (aOR=0.76, 95% CI=0.61, 0.95) were associated with reduced odds of any perceived gender-based discrimination. Among those who perceived gender-based discrimination (n=733), perceived discrimination scores were higher among women with increased age, medical illness, or history of military sexual trauma and lower among those who saw the same VA provider for most medical care. CONCLUSIONS: One third of women Veterans perceived gender-based discrimination in VA. Obtaining most medical care from the same VA provider and having a women's health clinic at one's VA were associated with less perceived discrimination.

History of unintended pregnancy and patterns of contraceptive use among racial and ethnic minority women veterans.

BACKGROUND: Nearly half of all pregnancies in the United States each year are unintended, with the highest rates observed among non-Hispanic black and Hispanic women. Little is known about whether variations in unintended pregnancy and contraceptive use across racial and ethnic groups persist among women veteran Veterans Affairs users who have more universal access than other populations to health care and contraceptive services. OBJECTIVES: The objectives of this study were to identify a history of unintended pregnancy and describe patterns of contraceptive use across racial and ethnic groups among women veterans accessing Veterans Affairs primary care. STUDY DESIGN: Cross-sectional data from a national random sample of women veterans (n = 2302) aged 18-44 years who had accessed Veterans Affairs primary care in the previous 12 month were used to assess a history of unintended pregnancy (pregnancies reported as either unwanted or having occurred too soon). Any contraceptive use at last sex (both prescription and nonprescription methods) and prescription contraceptive use at last sex were assessed in the subset of women (n = 1341) identified as being at risk for unintended pregnancy. Prescription contraceptive methods include long-acting reversible contraceptive methods (intrauterine devices and subdermal implants), hormonal methods (pill, patch, ring, and injection), and female or male sterilization; nonprescription methods include barrier methods (eg, condoms, diaphragm), fertility-awareness methods, and withdrawal. Multivariable logistic regression models were used to examine the relationship between race/ethnicity with unintended pregnancy and contraceptive use at last sex. RESULTS: Overall, 94.4% of women veterans at risk of unintended pregnancy used any method of contraception at last sex. Intrauterine devices (18.9%), female surgical sterilization (16.9%), and birth control pills (15.9%) were the 3 most frequently used methods across the sample. Intrauterine devices were the most frequently used method for Hispanic, non-Hispanic white, and other non-Hispanic women, while female surgical sterilization was the most frequently used method among non-Hispanic black women. In adjusted models, Hispanic women (adjusted odds ratio, 1.60, 95% confidence interval, 1.15-2.21) and non-Hispanic black women (adjusted odds ratio, 1.84, 95% confidence interval, 1.44-2.36) were significantly more likely than non-Hispanic white women to report any history of unintended pregnancy. In the subcohort of 1341 women at risk of unintended pregnancy, there were no significant racial/ethnic differences in use of any contraception at last sex. However, significant differences were observed in the use of prescription methods at last sex. Hispanic women (adjusted odds ratio, 0.51, 95% confidence interval, 0.35-0.75) and non-Hispanic black women (adjusted odds ratio, 0.69, 95% confidence interval, 0.51-0.95) were significantly less likely than non-Hispanic white women to have used prescription contraception at last sex. CONCLUSION: Significant racial and ethnic differences exist in unintended pregnancy and contraceptive use among women veterans using Veterans Affairs care, suggesting the need for interventions to address potential disparities. Improving access to and delivery of patient-centered reproductive goals assessment and contraceptive counseling that can address knowledge gaps while respectfully considering individual patient preferences is needed to support women veterans' decision making and ensure equitable reproductive health services across Veterans Affairs.

The Association between Mental Health Disorders and History of Unintended Pregnancy among Women Veterans.

BACKGROUND: Women Veterans have high rates of mental health disorders and other psychosocial factors which may render this population particularly vulnerable to negative health outcomes associated with unintended pregnancy. OBJECTIVE: The objective of our study was to assess the relationship between self-reported mental illness and history of unintended pregnancy among women Veterans. DESIGN AND PARTICIPANTS: Data are from a nationally representative, cross-sectional telephone survey of women Veterans, ages 18-45, who used VA for primary care within 12 months prior to interview (survey completion rate 83%). MAIN MEASURES: Predictors were self-report of any and number of mental health disorders (depression, anxiety, post-traumatic stress disorder, bipolar disorder, or schizophrenia). Outcomes were any and number of unintended pregnancies. Multivariable logistic and negative binomial regression were used to assess relationships between mental illness and unintended pregnancy. To assess women's current risk of unintended pregnancy, we examined associations between any mental health disorder and contraceptive use at last sex among heterosexually active women not desiring pregnancy. KEY RESULTS: Among 2297 women Veterans, 1580 (68.8%) reported a history of at least one mental health disorder, with 20.1, 21.6, and 27.0% reporting one, two, or three or more conditions, respectively. Any history of unintended pregnancy was reported by 1315 women (57.3%); 28.3% reported one, 15.6% reported two, and 13.4% reported three or more. Compared to women with no mental illness, women with any mental health disorder were more likely to report any unintended pregnancy (60.3 vs. 50.5%; adjusted OR 1.40; 95% CI 1.15, 1.71) and to have experienced greater numbers of unintended pregnancies (adjusted incidence rate ratio 1.29; 95% CI 1.15, 1.44). Increasing numbers of mental health disorders were associated with greater numbers of unintended pregnancies. Contraceptive use and method efficacy at last sex did not differ by mental health status. CONCLUSIONS: Women Veterans with mental health disorders are more likely to have experienced any and greater numbers of unintended pregnancies than Veterans without mental health disorders.

The Problems with Crisis Pregnancy Centers: Reviewing the Literature and Identifying New Directions for Future Research.

Crisis pregnancy centers (CPCs) are nonprofit organizations that present themselves as healthcare clinics while providing counseling explicitly intended to discourage and limit access to abortion. These facilities engage in purposefully manipulative and deceptive practices that spread misinformation on sexual health and abortion. CPCs have also been shown to delay access to medically legitimate prenatal and abortion care, which negatively impacts maternal health. Along with increasing anti-abortion legislation, the proliferation of CPCs paired with the closure of abortion clinics exacerbates the ongoing harmful impact these centers have on the reproductive healthcare landscape; however, despite their growing influence, there is still limited research on patients' understanding of and experiences with CPCs. This article provides a review of academic literature on CPCs and suggests future directions for research. Ongoing scholarship may aid in improving patient awareness and education regarding CPCs, an important step toward protecting reproductive autonomy.

The Burden of Abortion Restrictions and Conservative Diagnostic Guidelines on Patient-Centered Care for Early Pregnancy Loss.

Intrauterine pregnancies of uncertain viability are common, and guidelines for diagnosing early pregnancy loss must balance the risk of interrupting a viable pregnancy with the anxiety and medical complications resulting from delayed diagnosis. Two cases of likely early pregnancy loss presenting as intrauterine pregnancies of uncertain viability are described, with stark differences in care availability related to state reproductive health care regulations. Onerous abortion restrictions, medical and societal stigma, and inherent pronatalism in diagnostic criteria interfere with the exercise of clinical judgment and can damage patients' physical or mental health.

Perspectives of internal medicine physicians regarding medication abortion provision in the primary care setting.

OBJECTIVE: To better understand medication abortion attitudes and interest in future provision among Internal Medicine primary care providers (IM PCPs), and to characterize barriers to provision. STUDY DESIGN: We conducted a survey with IM attendings and trainees at a large academic medical center in Western Pennsylvania. We used descriptive statistics to characterize attitudes towards medication abortion provision, including the belief that it is within their scope of practice and interest in future provision, and to explore perceived barriers to provision. We used logistic regression models to assess factors associated with each of these attitudes. RESULTS: Of 397 eligible attendings and trainees, 121 (30%) completed the survey. Among those surveyed, 44% believed medication abortion is within the scope of practice of IM PCPs with trainees and female-identifying providers being significantly more likely to believe medication abortion is within their scope of practice compared to attending physicians and male physicians (60% vs 30%, p < 0.01 and 53% vs 31%, p = 0.01, respectively). Similarly, 43% endorsed interest in future provision, with trainees (67% vs 23%, p < 0.001) and female providers (54% vs 27%, p = 0.002) being more likely to express interest. The most cited barriers to provision included limited training in residency (70%) and low familiarity with abortion medications (57%). CONCLUSIONS: Many IM providers- particularly trainees- believe medication abortion is within their scope of practice and would like to provide this care. Interventions are needed to provide education and assistance complying with state and federal regulations to enable safe and efficient medication abortion provision by IM providers. IMPLICATIONS: IM departments and residency programs should seek to ensure training is offered to clinicians interested in providing medication abortion as a part of their primary care practice.

Pharmacy availability of emergency contraception in southwestern Pennsylvania: A simulated patient study.

OBJECTIVE: To assess the availability of oral emergency contraception in southwestern Pennsylvania pharmacies. STUDY DESIGN: We conducted a simulated patient study to assess on-the-shelf availability of levonorgestrel emergency contraception and immediate availability of ulipristal acetate emergency contraception. RESULTS: Only 44% of pharmacies stocked levonorgestrel on-the-shelf and only 5% of pharmacies had ulipristal acetate immediately available. CONCLUSIONS: We found significant barriers to obtaining timely oral emergency contraception in southwestern Pennsylvania. IMPLICATIONS STATEMENT: Timely access to emergency contraception is important for people's ability to determine if, when, how, and under what circumstances to have children. Pharmacies in southwestern Pennsylvania need to expand access to oral emergency contraception.

Adherence to Recommended Practices for Provision of Long-Acting Reversible Contraception Among Providers in a Large U.S. Health Care System.

Background: There is little research examining adherence to practice guidelines for long-acting reversible contraception (LARC). We assessed same-day LARC provision and adherence to other guideline-recommended practices among providers in a large academic health care system. Materials and Methods: We surveyed 363 providers who had billed using LARC-related codes within the prior 12 months. Primary outcomes were, for women requesting an intrauterine device (IUD) or implant, the typical number of visits for method provision and ability to add an insertion procedure to an annual examination. We used chi-square tests and multivariable logistic regression to identify characteristics associated with primary outcomes and described other practices and barriers to same-day LARC. Results: Our response rate was 42% (153/363). A typical single visit for women requesting an IUD or implant was reported by 37% of IUD providers and 51% of implant providers, respectively, and was associated with obstetrician-gynecologist specialty versus family medicine (IUD: 44% vs. 12%, p = 0.001; implant: 57% vs. 26%, p = 0.002) and practicing in the county of the main academic medical center versus any other county (IUD: 48% vs. 20%, p = 0.001; implant: 65% vs. 27%, p < 0.001). High ability to add LARC insertion to an annual examination was reported by 48% of IUD providers and 51% of implant providers, with similar associations of specialty and county. Barriers to same-day LARC included scheduling constraints, insurance and billing concerns, and device stocking. Nearly all respondents provide LARC to nulliparous women and adolescents. Among IUD providers, 73% schedule routine follow-up after insertion. Conclusions: Same-day LARC provision is low among providers in a large academic health care system. Provider-identified barriers suggest interventions to improve LARC access, including incentivizing device stocking and billing and insurance education.

Agreement between Self-Reported "Ideal" and Currently Used Contraceptive Methods among Women Veterans Using the Veterans Affairs Healthcare System.

BACKGROUND: Women veterans who use the Veterans Affairs Healthcare System theoretically have access to the full range of contraceptive methods. This study explores match between currently used and self-reported "ideal" methods as a potential marker of contraceptive access and preference matching. METHODS: This mixed methods study uses data from a nationally representative survey of reproductive-aged women veterans who use the Veterans Affairs Healthcare System for primary care, including 979 participants at risk of unintended pregnancy. Women reported all contraceptive methods used in the past month and were asked, "If you could choose any method of contraception or birth control to prevent pregnancy, what would be your ideal choice?" and selected a single "ideal" method. If applicable, participants were additionally asked, "Why aren't you currently using this method of contraception?" We used adjusted logistic regression to identify patient-, provider-, and system-level factors associated with ideal-current method match. We qualitatively analyzed open-ended responses about reasons for ideal method nonuse. RESULTS: Overall, 58% were currently using their ideal method; match was greatest among women selecting an IUD as ideal (73%). Non-White race/ethnicity (adjusted odds ratio, 0.68; 95% confidence interval, 0.52-0.89) and mental illness (adjusted odds ratio, 0.69; 95% confidence interval, 0.52-0.92) were negatively associated with ideal-current match in adjusted analyses; the presence of a gynecologist at the primary care site was associated with an increased odds of match (adjusted odds ratio, 1.35; 95% confidence interval, 1.03-1.75). Modifiable barriers to ideal method use were cited by 23% of women, including access issues, cost concerns, and provider-level barriers; 79% of responses included nonmodifiable reasons for mismatch including relationship factors and pregnancy plans incongruent with ideal method use, suggesting limitations of our measure based on differential interpretation of the word "ideal." CONCLUSIONS: Many women veterans are not currently using the contraceptive method they consider ideal. Results emphasize the complexity of contraceptive method selection and of measuring contraceptive preference matching.

Factors Associated with Choice of Sterilization Among Women Veterans.

Background: We sought to compare associations of contraceptive preferences, beliefs, self-efficacy, and knowledge with use of sterilization versus other methods of contraception. Materials and Methods: This is a secondary analysis of a telephone-based survey of a nationally representative sample of women Veterans not desiring future pregnancy. Contraceptive method used at last sex was categorized as female sterilization, long-acting reversible contraception (LARC), short-acting methods, or nonprescription methods/no method. Multinomial regression models were performed to compare the association between independent variables (contraceptive preferences, beliefs, self-efficacy, and knowledge) and use of sterilization versus other contraceptive methods. Results: Six hundred twelve women Veterans aged 18-44 years who were sexually active with men, had no history of hysterectomy or infertility, did not desire future pregnancy, and were not using male sterilization as their method of contraception were surveyed. A total of 208 women Veterans reported using female sterilization (34.0%). While method effectiveness was rated as extremely important by the majority of participants, there was no association between perceiving method effectiveness as extremely important and method selected in adjusted multinomial models. Women Veterans were more likely to use sterilization compared to hormonal methods of contraception if they reported that lack of hormones was an extremely important contraceptive method characteristic (aRRR 3.69, 95% CI 1.94-7.03). Women Veterans who strongly agreed with the belief that birth control decisions are mainly a woman's responsibility were less likely to use sterilization compared to LARC (aRRR 0.54, 95% CI 0.29-0.98). Conclusion: Associations between contraceptive preferences, beliefs, self-efficacy, and knowledge and use of sterilization in a population of women Veterans not desiring future pregnancy are complex, and decisions may not solely be driven by desire to select a highly effective method.

Financial Implications of 12-Month Dispensing of Oral Contraceptive Pills in the Veterans Affairs Health Care System.

IMPORTANCE: The Veterans Affairs (VA) health care system is the largest integrated health care system in the United States. Like most US health plans, the VA currently stipulates a 3-month maximum dispensing limit for all medications, including oral contraceptive pills (OCPs). However, 12-month OCP dispensing has been shown to improve continuation of use, decrease coverage gaps, and reduce unintended pregnancy in other practice settings. OBJECTIVE: To estimate the financial and reproductive health implications for the VA of implementing a 12-month OCP dispensing option, with the goal of informing policy change. DESIGN, SETTING, AND PARTICIPANTS: A decision model from the VA payer perspective was developed to estimate incremental costs to the health care system of allowing the option to receive a 12-month supply of OCPs up front, compared with the standard 3-month maximum, during a 1-year time horizon. A model cohort of 24 309 reproductive-aged, heterosexually active, female VA enrollees who wish to avoid pregnancy for at least 1 year was assumed. Probabilities of continuation of OCP use, coverage gaps, pregnancy, and pregnancy outcomes were drawn from published data. Costs of OCP provision and pregnancy-related care and the number of women using OCPs were drawn from VA administrative data. One-way and probabilistic sensitivity analyses were performed to assess model robustness. MAIN OUTCOMES AND MEASURES: Incremental per-woman and total costs to the VA of allowing for 12-month dispensing of OCPs compared with standard 3-month dispensing. RESULTS: The 12-month OCP dispensing option, modeled from the VA health system perspective using a cohort of 24 309 women, resulted in anticipated VA annual cost savings of $87.12 per woman compared with the cost of 3-month dispensing, or an estimated total savings of $2 117 800 annually. Cost savings resulted from an absolute reduction of 24 unintended pregnancies per 1000 women per year with 12-month dispensing, or 583 unintended pregnancies averted annually. Expected cost savings with 12-month dispensing were sensitive to changes in the probability of OCP coverage gaps with 3-month dispensing, the probability of pregnancy during coverage gaps, and the proportion of pregnancies paid for by the VA. When simultaneously varying all variables across plausible ranges, the 12-month strategy was cost saving in 95.4% of model iterations. CONCLUSIONS AND RELEVANCE: Adoption of a 12-month OCP dispensing option is expected to produce substantial cost savings for the VA while better supporting reproductive autonomy and reducing unintended pregnancy among women veterans.

Contraceptive Care in the Veterans Health Administration.

In recent years, the number of women Veterans obtaining care in the Veterans Affairs (VA) Healthcare System has grown, expanding the need for provision of contraceptive care. Women Veterans are a diverse group of women with complex sociodemographic and medical backgrounds, and meeting their needs presents a unique challenge for VA. Efforts including the establishment of comprehensive women's health clinics and training practitioners in women's health have greatly improved healthcare services for women Veterans over the last few decades. Recent data from a large cross-sectional survey study suggest that contraceptive use in VA is similar to the general population and that rates of unintended pregnancy, while still significant, are not higher than that in the general population. Subgroup analyses of this survey data, however, suggest that ongoing efforts are needed to improve outcomes in vulnerable subpopulations of women Veterans, particularly ethnic/racial minorities and Veterans with complex medical backgrounds. Policy changes such as the elimination of copayments for contraceptive prescriptions and the dispensing of more months of contraceptive supply are evidence-based starting points for improvements, in addition to leveraging VA's integrated system and research infrastructure to improve patient-centered counseling and contraceptive access.

Associations Between Perceived Susceptibility to Pregnancy and Contraceptive Use in a National Sample of Women Veterans.

CONTEXT: Women may be at risk for unintended pregnancy if they forgo contraception or use ineffective methods because they erroneously believe they are unlikely to conceive. However, the relationship between perceived susceptibility to pregnancy and contraceptive use is not fully understood. METHODS: Data collected in 2014-2016 for the Examining Contraceptive Use and Unmet Needs study were used to examine perceived susceptibility to pregnancy among 969 women veterans aged 20-45 who were at risk for unintended pregnancy and received primary care through the U.S. Veterans Affairs Healthcare System. Multivariable logistic regression was used to identify associations between perceived susceptibility to pregnancy (perceived likelihood during one year of unprotected intercourse) and use of any contraceptive at last sex. Multinomial regression models were used to examine method effectiveness among women who used a contraceptive at last sex. RESULTS: Forty percent of women perceived their susceptibility to pregnancy to be low. Compared with women with high perceived susceptibility to pregnancy, those with low perceived susceptibility were less likely to have used any contraceptive at last sex (86% vs. 96%; adjusted odds ratio, 0.2). Among contraceptive users, women with low perceived susceptibility were less likely than those with high perceived susceptibility to have used a highly effective method (26% vs. 34%; adjusted relative risk ratio, 0.6) or moderately effective method (34% vs. 39%; 0.6) at last sex. CONCLUSIONS: Identifying and addressing fertility misperceptions among women with low perceived susceptibility to pregnancy could help promote informed decision making about contraception and reduce the risk of unintended pregnancy.

Associations between Pregnancy Intention, Attitudes, and Contraceptive Use among Women Veterans in the ECUUN Study.

BACKGROUND: Although pregnancy intention is strongly associated with contraceptive use, little is known about the interaction between pregnancy intention and attitude, or how they jointly affect contraceptive use. METHODS: Cross-sectional data from a national survey of women veterans who receive care within the Veterans Affairs Healthcare System were used to examine relationships among pregnancy intention (in next year, in >1 year, never, not sure), attitude toward hypothetical pregnancy (worst thing, neutral, best thing), and contraceptive use among women at risk for unintended pregnancy. Bivariate and multivariable analyses assessed associations between pregnancy intention and attitude, both separately and jointly, with contraceptive use. Multinomial regression assessed the relationship of intention and attitude with contraceptive method effectiveness. RESULTS: Among 858 women at risk of unintended pregnancy, bivariate analysis demonstrated that pregnancy intention and attitude were associated, but not perfectly aligned. In logistic regression models including both variables, intention of never versus in next year (adjusted odds ratio [aOR], 2.78; 95% confidence interval [CI], 1.34-5.75) and attitude of worst thing versus best thing (aOR, 2.86; 95% CI, 1.42-5.74) were each positively associated with contraception use. Among women using contraception, intention of never (aOR, 3.17; 95% CI, 1.33-7.59) and attitude of worst thing (OR, 2.09; 95% CI, 1.05-4.17) were associated with use of highly effective (e.g., intrauterine devices and implants) versus least effective (e.g., barrier) methods. CONCLUSIONS: These findings support prior research suggesting that pregnancy intention alone does not fully explain contraceptive behaviors and imply that attitude toward pregnancy plays an important role in shaping contraceptive use independent of pregnancy intentions.