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Research roundup: January 2024 edition

Young people’s concerns about birth control and fertility, expanding EPT and PrEP in the ED, spike in EC demand around the New Year, and abortion decision making.

by Colleen Denny, MD and Emma Gilmore, MD

published 01/31/24

1. Concern that contraception affects future fertility: How common is this concern among young people and does it stop them from using contraception?

Prior studies show that many patients are concerned about the effect of contraception on fertility, but less is known about the specific details of this concern. Socioeconomic factors and social determinants of health may also affect the way that young people understand these risks. The authors of this study sought to better understand the way that young people think about contraception and future fertility by conducting surveys with more than two thousand community college students who were assigned female at birth. Researchers examined fears about contraception and fertility and their effect on contraception use, along with subject characteristics. The diverse sample was primarily between 18-19 years old and the majority were first-generation college students. Most participants (69%) worried about the effect of contraception on future fertility, and this often led to lower use of hormonal contraceptives. This fear was correlated with racial and ethnic disparities that may point to the United States’ history of reproductive coercion and racism. Providers should consider these factors to ensure counseling is addressing the concerns of young patients about birth control.

2. Patient Barriers to Discontinuing Long-Acting Reversible Contraception

Long-acting reversible contraception, or LARC, methods are preferred by many pregnancy-capable individuals, particularly when it is covered by insurance and same-day placement is available. Many studies have focused on equitable LARC access, but less is known about barriers to LARC discontinuation. However, LARC removal should be equally accessible to provide patients with reproductive autonomy and control over the timing of pregnancy and childbearing. The authors of this study conducted an online survey of nearly 400 individuals aged 18-50 who had used and discontinued (or tried to discontinue) LARC methods. Twenty-six percent of respondents reported at least one barrier to LARC removal, most commonly insurance access, and this experience differed by demographic factors such as race and education. These results suggest that health care disparities have a negative impact on reproductive justice for LARC users. Providers should be aware of this when counseling patients about removal, and keep in mind that discontinuation of LARC is as important as placement when thinking about patient access and autonomy.

3. Retail demand for emergency contraception in United States following New Year holiday: time series study

There is evidence suggesting that rates of vaginal intercourse without a method of contraception go up around the New Year Holiday. This is based on survey data linking New Year’s celebrations to increased sexual activity and alcohol consumption, which in turn is linked to higher rates of intercourse without a contraceptive method. This time period is also correlated with higher rates of sexual assault, in which contraception use is less likely. With this in mind, the authors of this study examined retail scan data to determine whether sales of one emergency contraception pill (levonorgestrel 1.5mg , or Plan B) increased during the New Year Holiday as compared to other holidays, such as Valentine’s Day, St Patrick’s Day, and Mother’s Day. They noted a significant increase in Plan B sales over the New Year Holiday, along with increased (though less) sales during Valentine’s Day, St Patrick’s Day, and US Independence Day. This data can be used to address behavioral risk factors and increase access to contraception and counseling for sexually active individuals at specific times of the year.

4. Efficacy of oral levonorgestrel emergency contraception with same day etonogestrel contraceptive implant: A prospective observational study

Patients seeking emergency contraception (EC) after intercourse can choose between two oral options, levonorgestrel or ulipristal, or two IUD options, non-hormonal IUD or levonorgestrel 52mg IUD). However, patients choosing either of the oral options will not have ongoing contraception, and there is the potential for some long-term contraception options to interfere with the effectiveness of oral EC when started at the same time. Furthermore, less is known about how the etonogestrel (ENG) implant may independently function as EC. In this prospective observation trial, the authors followed approximately 150 patients who were seeking EC and also desired same-day placement of the ENG implant. At one-month post-insertion, two patients had positive pregnancy tests; with ultrasound dating, these pregnancies were found to have been conceived five and eight days prior to study enrollment, respectively. The authors thus reported a pregnancy rate of 0.66% for oral EC and simultaneous ENG implant within five days of intercourse without the use of contraception, which is within the range of oral EC alone. This data suggests that patients who desire both oral LNG EC as well as an ENG implant for ongoing contraception may not need to delay implant placement.

5. Expanding expedited partner therapy and HIV prophylaxis in the emergency department

The United States is currently seeing increased cases of several different types of sexually transmitted infections (STIs), including chlamydia, gonorrhea, and syphilis, and this burden of STIs falls predominantly on younger patients as well as gender, sexual, and racial minorities. Many of these STIs may be initially diagnosed in emergency departments. In this review, the authors discuss the role of emergency medicine pharmacists (EMPs) in improving STI treatment and outcomes, including providing expedited partner therapy for STIs and PrEP for patients at increased risk of HIV infection. The authors review potential perceived barriers for EMPs to participate in care, including state-level restrictions and concerns for antibiotic or antiviral resistance, and provide a template workflow for incorporating EMPs into STI follow-up and provision of expedited partner therapy. Providers working in ED settings can use this work as a guideline for improving their own practices for managing STIs in their communities.

6. Trust in provider and stigma during second-trimester abortion

Although abortion is common in the United States, a significant amount of abortion stigma still exists. For other health conditions, such as HIV and obesity, stigma has been clearly associated with poor outcomes. While much less is known about the experience of stigma for individuals seeking an abortion, the authors of this study hypothesized that stigma could have a negative effect on abortion patients’ overall health status and should be explored. Additionally, they focused on trust in the abortion provider as a factor that might decrease patients’ experience of stigma. Results were drawn from questionnaire data in a sample of 70 participants seeking second-trimester abortion. The researchers found that trust in the provider and cohabitation were correlated with lower abortion stigma scores, while anxiety and depression were linked to higher abortion stigma. This study is a first step in exploring stigma for abortion patients to will hopefully inspire further study of trust-building and stigma-reducing interventions.

7. Prior Cesarean Birth and Risk of Uterine Rupture in Second-Trimester Medication Abortions Using Mifepristone and Misoprostol: A Systematic Review and Meta-analysis

When labor induction is initiated for term pregnancies, prostaglandins are not recommended for patients with a history of a cesarean birth due to the risk of uterine rupture. However, when second-trimester inductions are performed in the setting of fetal demise or abortion, prostaglandins such as misoprostol are considered to be safe. Currently, a combined regimen of mifepristone and misoprostol is recommended for medication abortion due to a range of benefits when compared to misoprostol alone, including time to expulsion and the likelihood of uncomplicated placental extraction. However, existing large-scale data on second-trimester uterine rupture is based on the use of misoprostol alone. The authors of this systematic review examined updated data to provide risk estimates when mifepristone and misoprostol are used. They extracted information about 7,118 patients who underwent second-trimester induction using a variety of medication protocols. Uterine rupture rates were 1.1% for patients with a prior cesarean birth and 0.1% for individuals without. Because of the large population reviewed in this study, these estimates are likely to be reliable and can be used to inform patient counseling.

8. Experiences with misoprostol-only used for self-managed abortion and acquired from an online or retail pharmacy in the United States

Medication abortion is a safe and effective form of pregnancy termination and can include both mifepristone followed by misoprostol or misoprostol alone. Legal and logistical barriers may preclude the use of mifepristone in some areas of the world and, increasingly, in areas of the United States where abortion is severely restricted. In this semi-structured interview study, the authors identified 31 patients who used misoprostol alone through Aid Access for their self-managed abortions (SMAs). In their interviews, the authors highlighted several themes, including patients’ understanding of medication abortion within the general context of other reproductive events such as miscarriage, childbirth, and menstruation, with accordant coping strategies. They discussed that younger patients without these contextual life events may need increased support, and also noted an overall preference for the mifepristone and misoprostol combination among those patients who had experienced both types of medication abortion. This research contributes to our knowledge of the safety and acceptability of misoprostol-only medication abortion among patients and highlights the importance of counseling, expectation setting, and publicly available information about SMA.

9. Pharmacist Provision of Medication Abortion: A Pilot Study

Restrictions on abortion access throughout the US since the Dobbs decision have highlighted the need for expanding abortion provision beyond only physician providers. In this pilot study, the authors adapted a toolkit for no-touch medication abortion to be provided by pharmacists, including both online and in-person training sessions, patient education materials, and checklists to guide care. Two pharmacists underwent this training and assessment before providing no-touch medication abortion with mifepristone and misoprostol to a total of 10 patients, with follow-up via phone call at one week and urine pregnancy test at home in four to five weeks. Nine out of 10 patients had successful medication abortions, with one requiring in-office aspiration of an ongoing pregnancy, with no serious adverse events noted. The authors conclude that this proof-of-concept study demonstrates a workflow by which pharmacists can safely and effectively provide medication abortion. LINK NEEDED

10. What attributes of abortion care affect people's decision-making? Results from a discrete choice experiment

Many variables may affect patients’ decisions about first-trimester abortion care, including the method of abortion (medication versus procedural) but also logistical considerations. In this online survey study of nearly 900 US residents between the ages of 18-55 who were assigned female at birth, the researchers queried participants’ preferences about abortion provision using discrete choice scenarios. These scenarios varied abortion method, but also cost, wait time, delivery model (in-person versus telehealth), and distance traveled. In their analysis, the authors concluded that while more patients (59%) had a slight or strong preference for medication abortion overall, wait time and cost had a greater impact than either the abortion method or delivery model. While the authors note that these preferences were in hypothetical situations, they note the overall preference among potential patients for medication abortion and highlight the importance of national efforts to expand this care model. However, they also note that patient preferences are not uniform, with some patients expressing a strong preference for procedural management and/or in-person evaluation and discuss that no single model of abortion care will meet all patient preferences.

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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