1. Safety and effectiveness of self-managed medication abortion provided using online telemedicine in the United States: A population based study
As legislation becomes increasingly hostile towards abortion in multiple states across the US, access to abortion is likely to decrease. Data suggests that, in parallel, self-managed abortion rates will rise. Self-managed abortion includes methods such as herbs, toxins, and self-injury, along with evidence-based medication abortion with mifepristone and misoprostol. Aid Access provides online consults for self-managed medication abortion in all 50 states in the US, but operates outside of the formal health care system. To evaluate self-managed medication abortion via telehealth, the authors of this study reviewed data from Aid Access on this regimen’s safety, efficacy, and acceptability. Aid Access collects information on adverse outcomes and patient experience, and researchers used the responses of patients over a one year period from March 2018 to March 2019. Of patients who opted for a medication abortion from Aid Access, the vast majority—over 96%—of patients confirmed successful resolution of their pregnancy, with only 1% reporting any adverse events such as blood transfusion or antibiotics. And patients were highly satisfied with this service. Overall, these results suggest that self-managed medication abortion provided by telehealth could be a safe, effective, and acceptable option in areas where abortion access is limited.
2. Increasing access to single-visit contraception in urban health care settings: Findings from a multi-site learning collaborative
When patients visit clinics seeking contraception, there are often barriers to same-day services, despite the fact that this is not reflected in official or scientific recommendations. Barriers may include requiring unnecessary lab testing, a need to obtain the requested birth control device, or a requirement for exams, which often lead to a second appointment for provision of the patient’s desired contraception. Unfortunately, evidence shows that patients often do not attend their second visit in this scenario, so these delays can lead to a decrease in access. Furthermore, these days appear to disproportionately affect people with lower incomes. The authors of this paper designed a quality improvement intervention, through a sexual and reproductive justice lens, to increase patient-centeredness and improve contraception access in New York City clinics. The team designed four main recommendations to improve access, which were adopted by the majority of participating sites. They subsequently noted an increase in uptake of contraception in both the primary care and postpartum settings. These results suggest that the implementation of quality improvement recommendations can yield noteworthy results, even in a large, urban, complex health care setting. This is an innovative approach to increasing access that could be utilized by health care systems across the US.
3. Intrauterine device, subdermal contraceptive, and depot medroxyprogesterone use among transmasculine and cisgender patients over a 10-year period
Transgender people may face discrimination in health care settings, and often have difficulty obtaining access to reproductive health care, including contraception. Transmasculine is a term used to describe people who were assigned female at birth but do not identify as female—including gender non-binary, transgender, and agender individuals. Transmasculine patients may be at risk of pregnancy, or may wish to avoid menses, but report difficulty accessing gynecologic or contraception-based care. The authors of this study theorized that longer-acting contraception, such as intrauterine devices (IUDs), subdermal contraceptives (such as the Nexplanon), and injections (like Depo-Provera) would help address pregnancy and menstrual concerns in transmasculine patients. They performed a cross-sectional study to assess the uptake of these methods when comparing transmasculine and cisgender populations seeking care at Kaiser in Northern California over a span of 10 years. The authors found that uptake of IUDs, implants, and Depo increased over the study time span, and the increase in transmasculine patients was greater—though overall rates of use were higher in the cisgender population. These findings suggest that there has been an improvement in access for transmasculine patients, but further research is needed to better understand how to provide reproductive health care for this population.
4. A prospective analysis of the relationship between sexual acceptability and contraceptive satisfaction over time
While contraception is one of the most commonly used medications in the United States, there is limited understanding of the reasons that individuals change or discontinue specific methods. In particular, little is known about sexual acceptability or the way a birth control method affects a patient’s sexual well-being and how that impacts a patients’ preferences regarding contraception. The authors of this study hypothesized that sexual acceptability would have a positive impact on contraceptive satisfaction. They analyzed data from a prospective cohort study of new contraceptive users in Utah, looking specifically at contraception satisfaction and sexual acceptability. Their results demonstrated a strong correlation between impact on sex life and contraception satisfaction. People who reported that their method improved their sex life “a lot” had a nearly eight times increased odds of contraception satisfaction at three months. A decrease in bleeding pattern was also correlated with contraception satisfaction, though to a lesser degree. These findings suggest that a contraceptive method’s impact on sexual well-being is significantly linked to patient satisfaction. However, this is a poorly understood aspect of patient wellness, and further research is needed to better understand this relationship.
Racial health inequities have a particular impact on the reproductive health of Black women in the United States. While the impact of systemic racism is known to contribute to a number of poor maternal and neonatal health outcomes in obstetrics, racial health inequities extend beyond obstetrics to nearly every reproductive health domain. In this structured interview study, the authors sought to better characterize the lived experience of racism and its associated effects in the field of reproductive health care. In interviews with 21 participants ages 18 to 45 years old who self-identified as Black and were assigned female at birth, the authors identified themes common across participants in their interactions with the reproductive health care system. Participants described several aspects of societal systemic racism that impacted their reproductive health care, including early sexualization of Black women and girls, heightened awareness of reproductive health disparities, and the impact of a known history of reproductive oppression in the US. Participants reported anti-Black racism within the health care system in many forms, including the absence of shared-decision making, stereotyping, and invalidation and dismissal by health care providers. Finally, many participants discussed actions that they themselves took to counterbalance racism within the health care system, including seeking providers of color, enlisting advocates outside the system, seeking care only when desperate, and heightening their symptoms. These findings illustrate the multifaceted ways that systemic racism manifests in reproductive health care in the US, and the authors call on institutions providing such care to recognize these phenomena at the institutional and individual provider level.
6. An exploratory study comparing the quality of contraceptive counseling provided via telemedicine versus in-person visits
The COVID-19 pandemic accelerated the incorporation of telehealth into many aspects of health care in the US, including reproductive health care. Many advocates for telehealth cite its convenience and accessibility for visits focused on contraceptive counseling, but less data are available regarding the quality of telehealth contraception counseling in comparison to traditional in-office counseling. In this cross-sectional study surveying 110 patients who had either a synchronous video telehealth visit or in-office contraception counseling visit, the authors used the validated Interpersonal Quality of Family Planning (IQFP) scale to evaluate contraception counseling quality. They found that demographics data was overall similar between both groups, and that IQFP scores were not significantly different between them. There were no significant differences between the types of contraception ultimately chosen between the two groups of study participants, including permanent sterilization. The authors did find, however, that patients in the telehealth group were more likely to have had previous experience with telehealth and report favorable impressions of telehealth. These findings suggest that high quality contraception counseling is feasible through telehealth visits, especially for patients who already feel favorably towards telehealth.
Early identification of pregnancy may improve health outcomes for pregnant patients, either by facilitating earlier entry to prenatal care, or, for patients who opt for abortion, by reducing the costs of abortion care and lowering the chances of complications. However, approximately 25% of pregnant patients do not discover pregnancy until later than seven to eight weeks. And pregnancies among adolescents, Black and Latinx patients, and/or patients who describe their pregnancies as unintended are all more likely to be identified later. In this cross-sectional survey, the authors examined how the use of home pregnancy tests contributed to pregnancy awareness. In surveying 188 respondents presenting to care at one of eight reproductive or primary health care facilities across the US, the authors found that 74% of all patients who suspected pregnancy took a home test before presenting to care, but only 65% of adolescents did so. Overall, those testing at home identified their pregnancy on average 10 days earlier than those who did not. Of those not testing at home, the most common reasons given were distrust of the test’s accuracy and difficulty accessing a test. In terms of gestational age, 35% of those surveyed identified their pregnancies after six weeks gestation, and these percentages were higher among those who identified as Latina, noted food insecurity, and those with unplanned pregnancies. The authors conclude that despite the availability of home pregnancy testing, early gestational age abortion bans will still predominantly affect already marginalized patient populations that face barriers to test procurement and use.
In the United States, approximately 1.46%, or 52,000 pregnant patients per year, experience severe maternal morbidity (SMM), defined as a complication during pregnancy or postpartum that causes significant maternal harm or risk of death. Chronic disease, having Medicaid or no insurance, and/or identification as a racial or ethnic minority all have been shown to increase the risk of SMM. While preconception care has been suggested as a mechanism for reducing SMM, its benefit has not been definitively shown. In this secondary analysis of Medicaid claims data, the authors examined the correlations between demographic factors, preventative health care in the year prior to conception, and SMM as defined by the CDC’s International Classification of Diseases. In more than 1.5 million unique births, the authors found that overall 1.74% of births were affected by death or SMM and if transfusion alone was excluded, 0.63% were affected by SMM. Consistent with existing data, patients from racial and ethnic minorities were more likely to experience SMM, along with older patients, patients with short interval pregnancies, patients with a history of SMM, and patients with medical comorbidities. However, after adjusting for covariates, the authors found that receiving any preconception care, particularly contraception services, was associated with decreased risk of SMM. Preconception care was also associated with decreased SMM among patients with comorbidities such as chronic hypertension, diabetes, and chronic kidney disease. While the authors caution that causality cannot be definitively determined, this large study demonstrates a clear association between preconception care, particularly contraception services, and SMM.
Tubal ligation remains a common preference for contraception for individuals in the United States and has particularly high rates among low-income patients and those with chronic disease. However, there is also evidence that publicly-insured patients are more likely to ask for a reversal of tubal sterilization, which may not be covered by their insurance. It is therefore critical to understand the efficacy of long-acting reversible contraception (LARC)—such as IUDs—as compared to tubal ligation to provide counseling for patients weighing their contraceptive options for long-term methods. The authors of this study analyzed Medicaid data on tubal ligation and IUD for patients in California over a six-year time span. In reviewing more than 60,000 patients, they found that one-year pregnancy rates were lower in patients with a levonorgestrel IUD than after tubal ligation, but similar in patients who had a copper IUD and those who had a tubal ligation. However, post-procedure complication rates, such as infection and pelvic pain, were higher in patients who opted for tubal ligation. This information suggests that patients can be reassured about the efficacy of IUD options when they are seeking information about long-term contraception.