Research roundup: January 2020 edition

The CDC’s 2020 recommendations for evidence-based STD care, telehealth abortion consultations to help patients overcome barriers to care, a systematic review of the use of misoprostol prior to IUD insertion, and more.

by Colleen Denny, MD and Emma Gilmore, MD

published 01/31/20

1. Recommendations for Providing Quality Sexually Transmitted Diseases Clinical Services, 2020

The CDC has released 2020 guidelines to guide primary care and emergency providers caring for patients who need screening and/or treatment for STDs, meant to complement its previously published Sexually Transmitted Diseases Treatment Guidelines from 2015. Given the decreasing number of freestanding STD clinics in the United States, these new guidelines are a key resource on caring for patients in different clinical settings, including appropriate on-site diagnosis and treatment as well as when to refer to partner services and specialists. The guidelines discuss history-taking and physical exam strategies for STD-related care, prevention modalities such as vaccination and PrEP prescription, availability, and recommendations for on-site testing, partner therapy, facility laboratory requirements, and indications for specialist referrals. These recommendations serve as a useful guideline for primary care providers seeking to provide evidence-based STD care.

2. Characteristics of patients having telemedicine versus in-person informed consent visits before abortion in Utah

In some regions of the United States, targeted restrictions on abortion providers, also known as TRAP laws, require a mandatory waiting period between a patient’s evaluation for a desired abortion and the actual abortion procedure. This requires patients to make two separate visits to a facility, resulting in increased burdens of travel, childcare, and/or work absences for patients. In response to a mandatory 72-hour waiting period in Utah, Planned Parenthood Association of Utah began offering telemedicine consultations to its patients in lieu of an in-person visit for informed consent in 2015. In this retrospective cohort study, the authors evaluated the characteristics of patients who opted for a telemedicine consultation for informed consent rather than a traditional in-person visit. In more than 9,000 visits, they found that an increasing percentage of patients opted for telemedicine consultations in the three years after implementation, and that these patients were more likely to be older, have children, live further from the clinic, and opt for medication abortion after counseling. The authors concluded that offering this telemedicine consultation provided an opportunity to ameliorate at least some of the burden imposed by the waiting period on patients, especially for those living significant distances from an abortion provider.

3. Emotions and decision rightness over five years following an abortion: An examination of decision difficulty and abortion stigma

Despite a lack of good evidence, the argument that abortion leads to patient regret has long been used as an anti-abortion stance by some activists. This study uses 5 years of data to examine patients’ actual feelings after abortion. The authors used data from the Turnaway Study, which recruited almost 700 individuals seeking abortions, and examined their emotions regarding the abortion and whether it was the right decision. Patients were recruited between 2008-2010 and semiannual phone interviews were concluded by 2016. Although the surveyed individuals recognized the difficulty of their decision, relief was the most commonly felt emotion by participants at all times. Furthermore, by the conclusion of the study, 99% felt that abortion was the right decision. Authors found that patients’ perceptions about abortion stigma in their communities, along with decision difficulty, were the most significant predictors of their feelings over time. Overall, this study provides important insight as to the trajectory of patients’ perceptions regarding their abortions over time and indicates that further study may be necessary to examine the ways that abortion stigma affects patient decision-making difficulty and regret.

4. Self-managed abortion

Self-managed abortion describes any abortion happening outside a clinical setting and has existed in multiple forms throughout history, but its political and medical relevance is changing as state laws become increasingly restrictive. The authors of this article examine self-managed abortion (SMA) within its current legal, political, and evidence-based context. The authors found that as many as 10% of reproductive-aged women are seeking information about SMA online, including attempts to purchase medical abortion medications through websites. These numbers have gone up as more parts of the US have lost the services of abortion providers locally. To counteract this lack of access to local resources, telemedicine remains a promising avenue for provision of reproductive health care services, including abortion, as it is safe, effective, and the majority of clinicians support its use. Regarding legal risk of SMA, several states have already criminalized it and others are likely following this example. Overall, SMA appears to be a safe option for many patients, and the authors recognize that its incidence is likely to increase in the current political landscape of the United States. This article is important background reading for reproductive health care providers in order to understand the changing context of abortion care and possible next steps in abortion provision.

5. Coverage of immediate postpartum long acting reversible contraception has improved birth intervals for at risk populations

In this study based out of South Carolina, the authors set out to examine changes since the state revised Medicaid policy to cover use of immediate long-acting reversible contraception (LARC) in 2012. Researchers analyzed use of immediate postpartum period (IPP) LARC from 2010-2017, comparing years prior to and after this legislative change. They looked at variations in use based on number of prenatal care visits, location (defined as metropolitan vs non-metropolitan), and medical comorbidities, along with frequency of short pregnancy interval, which can lead to adverse outcomes for mother and fetus. Overall, use of both postpartum and IPP LARC increased after this policy change. Interestingly, an increased number of women opted for postpartum LARC after this legislative change, while a new group chose to obtain IPP LARC, showing that these populations are not interchangeable. Women with fewer prenatal care visits and medical comorbidities, as well as those in metropolitan areas were more likely to opt for IPP LARC. Both IPP and postpartum LARC were associated with a decrease in the rate of short interpregnancy interval. The authors attribute increased access to and use of IPP LARC on improved insurance coverage and acknowledge its positive effect on public health, while they note the need for ongoing patient outreach and education particularly in rural areas.

6. Patient perceptions of immediate postpartum long-acting reversible contraception: A qualitative study

While the provision of immediate postpartum LARC methods may allow patients to have access to a preferred contraceptive method that would otherwise require a separate visit or increased out-of-pocket costs, as seen in the previous study about increased access to IPP LARC, providers must also be conscious of the potential for patients to feel pressured into choosing LARC at a particularly vulnerable time in their lives. In this qualitative study, the authors interviewed 17 women about their experiences with immediate postpartum LARC and identified several common themes. The participants praised the ease and convenience of postpartum LARC and discussed that they preferred having multiple opportunities to discuss their contraceptive options during their antepartum visits, including with multiple different providers. However, some participants also reported feeling “pushed” to choose LARC and wondered about receiving biased counseling because of their socioeconomic background. These themes reflect the overarching ideas of reproductive justice—that access to postpartum LARC, while appreciated by patients, must also be accompanied by supportive care relationships that clearly prioritize and promote the patient’s right to make decisions about their overall reproductive well-being including if, when, and under what circumstances to get pregnant and how to parent.

7. Contraceptive counseling practices and patient experience: Results from a cluster randomized controlled trial at Planned Parenthood

Contraceptive counseling is known to be a tool with powerful potential, but it has not been well studied or standardized. For this study, 10 Planned Parenthood Centers participated in a cluster randomized controlled trial in 2016-2017, with half of the centers undergoing an evidence-based standardized training program designed to support patients. Training was directed towards auxiliary staff within clinics and patients were surveyed with regular follow-up after one and three months. Almost 600 patients completed the initial intervention and at least one follow up survey. Patients who received contraceptive counseling from the providers who completed the standardized training program expressed a greater degree of baseline satisfaction. However, there was no difference in contraceptive-related behaviors over time between groups. Overall, this study indicates that standardized, evidence-based counseling is likely to have positive effects on patient experience, but ongoing research is needed to further quantify its effect and to design further targeted improvements to patient counseling programs.

8. Pregnancy preferences and contraceptive use among US Women

In order to better understand the relationship between pregnancy preference and use of contraception, the authors of this study implemented a new tool called the Desire to Avoid Pregnancy (DAP) scale. The DAP scale is the first of its kind, designed to thoughtfully evaluate patients’ desires, emotions, and perceived consequences with regard to pregnancy using a Likert scale. About 500 women were recruited from health care facilities in five states. Desire to avoid pregnancy was strongly associated with contraceptive use, though pregnancy preferences did not influence the type of contraception used. Interestingly, women with a low pregnancy preference, meaning they have a lower desire to avoid pregnancy, also tended to use contraception. Overall, the study’s results demonstrate patients’ diversity when integrating pregnancy preference and contraception choice into their lives. The authors highlight that providers should keep these nuances in mind when discussing contraception and pregnancy planning with patients.

9. Contraceptive counseling should be offered to all patients initiating testosterone as gender-affirming hormone therapy

Care for transgender individuals is important for reproductive health care providers, but there is still a lack of cohesive training with regard to these patients’ birth control needs. This article serves as a comprehensive guide for providing care to transmasculine patients—those who were assigned female at birth but who identify as male or non-binary. The authors have provided extensive information on appropriate, safe language and discussion points when caring for transmasculine patients. They also discuss the pathophysiology behind testosterone treatment that may still allow patients to become pregnant, even with the absence of menses, and provide a guideline for contraceptive counseling with recommendations regarding the most suitable options, including IUDs and the etonorgestrel implant. The unique impact of these methods’ side effects is also discussed with regard to this patient population. This is fundamental reading for providers caring for transmasculine patients.

10. Misoprostol administration prior to intrauterine contraceptive device insertion: a systematic review and meta-analysis of randomised controlled trials

While intrauterine devices (IUDs) provide a long-term reversible option for contraception for people regardless of parity, IUD placement may be more challenging and/or painful for patients who have not had a previous vaginal birth. This may lead to reluctance for providers to recommend or offer IUDs to adolescent or nulliparous individuals, which in turn has led to efforts to identify mechanisms to improve the ease and comfort of IUD placement for these patients. This systematic review and meta-analysis identified 14 studies investigating whether premedication with misoprostol improved the ease, success, and comfort of IUD insertion. The authors concluded that while premedication with misoprostol increased successful placement rates in patients with previous failed attempts and in those with a history of C-section, it did not help with placement for nulliparous patients. Vaginal misoprostol led to increased success rates in some groups, with decreased side effects, but buccal or sublingual administration was not found to be effective and was associated with more side effects such as pain and nausea. While the authors conclude that routine use of misoprostol prior to IUD placement is not supported by evidence, providers may consider using vaginal misoprostol in those patients with a history of failed placement and/or C-section delivery.

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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