Research roundup: August 2020 edition

The benefit of ultrasound guidance in IUD placement for patients with retroverted uteri, a demonstrated need for trauma-informed care in sexually-transmitted disease clinics, demand among abortion patients for more autonomous care options, and more.

by Colleen Denny, MD and Emma Gilmore, MD

published 08/31/20

1. The value of ultrasound guidance during IUD insertion in women with RVF uterus: A randomized controlled trial

In-office placement of IUDs can be challenging, particularly for patients with less common uterine anatomy. In this randomized controlled trial, the authors investigated whether the planned use of transabdominal bedside ultrasound during IUD placement improved patient experience and outcomes for patients with retroverted uteri. In comparing the outcomes of 400 patients, the authors found that the group with ultrasound-guided IUD placement reported lower pain scores, with shorter procedure times, and providers reported easier placements when compared to the blind-placement group. Complications were also less common in the ultrasound group, including bleeding, cramping, and IUD placement failures. If ultrasound is available in their facilities, providers who note a retroverted uterus in a patient desiring IUD placement can consider intra-procedure ultrasound guidance to facilitate placement and improve patient experience.

2. A need for trauma informed care in sexually transmitted disease clinics

Sexually transmitted diseases (STDs) have enormous implications for public health, including economic burden and long-term health outcomes, including cancer risk. The authors of this study also note that there is a well-documented link between STDs and a history of violence. They performed this literature review in order to further document this relationship, and to discuss ways to better incorporate trauma-informed care (TIC) into STD clinic operations. Ultimately, the authors found links between STD incidence and childhood sexual abuse and intimate partner violence. Interestingly, some studies also noted an association between STDs and community violence (for example, individuals exposed to high crime rates in their neighborhoods). Researchers then identified three specific areas for improvement: intake screening for violence at clinics, increased network of interdisciplinary services (such as access to housing and substance abuse resources), and increased utilization of TIC. They concluded that further research is needed to understand how best to incorporate TIC into STD clinics.

3. Expulsion of intrauterine devices after postpartum placement by timing of placement, delivery type, and intrauterine device type: a systematic review and meta-analysis

Postpartum IUD placement may occur immediately after delivery (within 10 minutes after placenta delivery), early inpatient (10 minutes until 72 hours after delivery), early outpatient (more than 72 hours but less than 4 weeks since delivery), and interval (more than 4 weeks after delivery). However, previous research has indicated that IUD placement at these intervals is associated with varying risks of expulsion, which is an important feature when counseling patients. In this meta-analysis, the authors pooled 48 studies of postpartum IUD placement published in the last 20 years for a combined 7,500 patients. While they found that immediate placement IUD expulsion rates were higher than interval expulsion rates (10.2% vs 1.8%), this varied both by type of delivery, with C-section having lower expulsion rates than vaginal delivery, and type of IUD, with levonorgestrel IUDs having higher expulsion rates than copper IUDs. Furthermore, the authors found that early outpatient IUD expulsion rates were lower than expected, at 0%, though this was limited by a smaller number of patients in this interval group. Providers may use these findings to counsel patients about options for postpartum IUD placement, and may consider adding an early outpatient placement for patients, especially for patients already visiting the clinic setting for reasons of infant visits or early postpartum follow up.

4. Knowledge, interest, and motivations surrounding self-managed medication abortion among patients at three Texas clinics

As some regions of the country enact more legislation restricting abortion access, patients desiring abortion may consider self-managed abortion, without the oversight of a trained abortion provider. As patients who opt for self-managed abortion do not necessarily interact with the health care system, it is difficult to assess how widespread the practice of or knowledge about self-managed abortion is. In this survey-based research, the authors provided anonymous surveys to approximately 1,500 patients seeking abortions within the medical setting to determine their understanding of and interest in self-managed abortion. Approximately one-third of surveyed patients had prior knowledge of self-managed abortion, a similar percentage reported considering it as an option for themselves, and approximately 13% had actively sought out or attempted a self-managed abortion before their clinic visit. Of those without prior knowledge, 39% expressed interest in the option of self-managed abortion. The authors concluded that barriers to clinic access affected interest and engagement with self-managed abortion, and that there is a demand among patients for more autonomous abortion care options.

5. Association of Immediate Postpartum Etonogestrel Implant Insertion and Venous Thromboembolism

Immediate placement of etonogestrel implant (Nexplanon) is emerging as a recommended practice, particularly as many patients resume intercourse prior to their postpartum visit (and only 60% of patients present to their postpartum visit at all). However, the Nexplanon (etonorgestrel implant) package insert recommends waiting 21 days prior to placement due to possible risk of venous thromboembolism (VTE). The authors of this study sought to better understand this link by reviewing 30-day postpartum readmissions for VTE in patients who underwent immediate postpartum Nexplanon placement. Using a national readmission database, they found no increased association between immediate Nexplanon placement and 30-day readmission for VTE. However, the authors noted that their sample size was under-powered. Overall, they concluded that their findings certainly warrant a conversation with patients about the risks and benefits of immediate placement, particularly given the barriers many patients face with regard to their postpartum visit.

6. Missed Opportunities for Discussing Contraception in Adolescent Primary Care

While the majority of patients under age 18 are sexually active and account for approximately half of newly diagnosed STIs, providers seeing adolescent patients may not regularly ask about sexual health practices and/or counsel about contraception. Further, the majority of adolescent visits are for acute issues; only 40% of adolescents obtain a yearly preventative care visit. In this retrospective chart review of more than 12,000 adolescent care visits, the authors investigated how frequently providers asked patients about contraception and how many visits occurred before contraception was brought up. Approximately 82% of visits included discussion of contraception, but patients with prior visits had an average of three visits before providers discussed contraception. Approximately 60% of patients questioned were using a method of contraception, including abstinence; approximately 15% of these patients chose a new method after counseling. Of those patients who did not use contraception, 40% left with a new method after counseling. There were also differences in the demographics of both patients and providers in encounters including contraception counseling: older, female, and Hispanic patients on public insurance were more likely to be asked about contraception, and female providers were more likely to engage patients about contraception. Providers seeing adolescent patients can use these findings to incorporate contraception counseling into both their follow-up visits as well as preventative care visits, and to standardize such counseling regardless of the demographics of a given adolescent patient.

7. Understanding the extent of contraceptive non-use among women at risk of unintended pregnancy, National Survey of Family Growth 2011-2017

Efforts to reduce unintended pregnancy often begin with efforts to understand why patients at risk of pregnancy do not use contraception, and to tailor health outreach campaigns accordingly. Using National Survey of Family Growth data from 2011 to 2017, the authors attempted to determine factors associated with whether patients between age 15-44 used contraception. They found that approximately 20% of respondents were standard non-users of contraception, using a broad definition. However, when the authors refined the definition to specify patients who could reliably be considered non-users, such as excluding patients who had not had sex in the last 12 months or those who were anticipating pregnancy in the next two years, this number decreased to 5.7% of respondents. When adjusting for other factors, this smaller group was more likely to be expecting a birth within 2–5 years and have a parity of one. The authors suggest that this more refined definition of contraceptive non-use could help tailor public health policy, and recommend that a broader array of contraception methods, including coital-dependent methods and adequate pre-conception counseling, should be available to patients.

8. Unsatisfied contraceptive preferences due to cost among women in the United States

With the advent of the Affordable Care Act (ACA), cost-related barriers to contraceptive access have decreased, but many obstacles remain, particularly for individuals living in states with limited Medicaid and Title X Family Planning Program funding. For this study, researchers sought to determine the degree of cost-related barriers to patients’ contraceptive choices along with other associated characteristics. The authors found that 22% of surveyed women would prefer to use a different method of contraception if cost were not an issue. Furthermore, they found that this barrier was also associated with races and ethnicities other than white, younger age, lower income, and either a lack of insurance or public insurance. These findings further highlight the barriers to access for disadvantaged patients and emphasize the need for supportive programs to help individuals shoulder the cost of contraception. It is clear that adequate provision of birth control includes consideration of economic burden, and providers should be mindful of this obstacle when making shared decisions with patients.

Colleen Denny, MD, is an attending ObGyn at Bellevue Hospital in New York City, where she is the Medical Director of the Women's Clinic, and a clinical assistant professor with the NYU School of Medicine. She enjoys providing care for patients in all phases of life and is especially interested in issues related to contraception access and public health. Outside of work, she’s a runner, a dancer, and a bit of a crossword puzzle nerd.
Emma Gilmore is a fellow in Complex Family Planning at the University of Pennsylvania. She completed her residency in Obstetrics and Gynecology at New York University. She's passionate about reproductive rights, medical education, and combating health care disparities, particularly in sexual and reproductive health. In her free time, she can be found taking her dog on walks around the beautiful parks in and around Philadelphia.
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