Perspectives on Sexual and Reproductive Health最新文献

Background: Adolescent contraceptive decision-making is influenced by a number of patient and clinician-driven factors. Although the AAP continues to endorse an efficacy-based model of contraceptive counseling, many professional organizations are shifting to a shared decision-making model as the optimal approach for providing unbiased and patient-driven contraceptive counseling. While SDM is intended to reduce the influence of clinician bias, it can exacerbate inequity if a clinician tailors a conversation based on their assumptions of a patient's goals or preferences. In this qualitative study, we explored self-reported contraceptive counseling practices among US-based clinicians who see adolescent patients to assess how these practices create barriers or facilitators to SDM and person-centered contraceptive care.

Methods: We interviewed 16 clinicians at the 2022 AAP Annual Meeting who counsel adolescent patients about contraception. We used thematic content analysis to analyze interview transcripts using Dedoose.

Results: We identified six aspects of contraceptive counseling that clinicians commonly employed with adolescent patients. These were: (1) sociodemographic characteristics driving counseling, (2) reliance on tiered effectiveness counseling, (3) initiating counseling conversations using "ask then explain" or "explain then ask" approaches, (4) emphasis on teen pregnancy prevention, (5) the influence of method accessibility on counseling, and (6) parental involvement in decision-making and patient confidentiality. We describe how these themes align with or diverge from each component of the SDM framework.

Conclusion: Clinicians in this study frequently engaged in non-patient-centered techniques during contraceptive counseling with adolescents. These findings can inform practice recommendations to support clinicians in providing high-quality contraceptive counseling using shared decision-making.

Context: Medicaid is a major funder of reproductive health services, including family planning and pregnancy-related care, especially for people with limited income and people of color. Federal Medicaid funds cannot be used for abortion however 16 states allow state Medicaid funds to pay for abortion. In recent years, Illinois and Maine implemented, and West Virginia discontinued, state Medicaid coverage of abortion.

Methodology: With retrospective procedure- and patient-level data obtained from clinics in these three states, we used an interrupted time series design, multivariable regression models, and descriptive statistics to assess changes in procedure volume and patients' share of total procedure price (patient price).

Results: In Maine and Illinois, implementing state Medicaid coverage of abortion contributed to an immediate overall increase in abortion access (as seen by a rise in monthly procedure volume at the time of the policy's implementation), a decrease in patient price (by 36% in Maine and 44% in Illinois) after policy implementation as compared to pre-implementation, and overall improved access among people of color. Conversely, when West Virginia discontinued coverage, access to care decreased, patient price increased by 130%, and the share of abortion procedures among people of color decreased.

Conclusions: In the fragmented abortion access landscape of the post-Roe era, our study provides new evidence that financial assistance offered through state Medicaid policies that cover abortion may be most helpful to those facing traditional structural inequities to access, while discontinuation of Medicaid coverage of abortion further burdens those already economically marginalized.

On January 30, 2024, over 300 researchers filed an amicus brief in FDA v. Alliance for Hippocratic Medicine, a United States (US) Supreme Court case that could have severely impacted access to mifepristone, one of the two drugs commonly used in medication abortion. The researchers summarize the legal challenges to the US Food and Drug Administration's (FDA's) original approval of mifepristone in 2000 and its 2016 and 2021 decisions modifying mifepristone's Risk Evaluation and Mitigation Strategy (REMS) Program and label, the responses from the FDA and drug manufacturer to the challenges, and the potential implications of the Court's decision on access to mifepristone in the US. The researchers detail how the FDA relied on a robust scientific record analyzing tens of thousands of patient experiences that conclusively demonstrated the safety and effectiveness of the changes to the mifepristone REMS Program and label and urge the Supreme Court to rely on the clear scientific record and preserve access to mifepristone without reimposing restrictions. What follows is a reprint of this brief.

Introduction: Although menstruation is a natural biological process, many people feel embarrassed of their menses and struggle to discuss it. To mitigate menstrual communication stigma, it is necessary to first elucidate communication experiences and perceptions. Thus, we qualitatively explore menstrual communication among cisgender women who menstruate and their family, friends, healthcare providers, and community.

Methodology: In partnership with No More Secrets (NMS), a Philadelphia menstrual health non-profit, we conducted a community-based participatory research (CBPR) project in Fall 2020. Cisgender, menstruating individuals ages 18-45 recruited from NMS' catchment in Philadelphia participated in semi-structured interviews about their menstrual experiences and communication (N = 20). A deductive, theory-driven approached based on the social-ecological model was used to analyze the data.

Results: Varying emotional responses arose across social-ecological levels: communication was awkward and simplistic with family; positive and supportive with friends and community members; and uncomfortable and frustrating with healthcare providers. Participants echoed the importance of menstrual communication as a means of sharing information, feeling less alone, and decreasing menstrual stigma.

Discussion: Findings can inform future CBPR workshops that address stigma in familial, healthcare, and community-based discussions to improve menstrual health and experiences for cisgender girls and women, transgender men, and gender non-binary individuals who menstruate.

On January 30, 2024, over 300 researchers filed an amicus brief in FDA v. Alliance for Hippocratic Medicine, a United States (US) Supreme Court case concerning the regulatory status of mifepristone, one of two drugs used in medication abortion. In this Comment we summarize the legal challenge, responses from the FDA and drug manufacturer to these challenges, oral arguments presented before the Court, and the implications of the Court's decision on access to mifepristone in the US. We also summarize the content of the accompanying amicus brief.

Objective: We describe the experiences and preferences of women who switched from clinic-administered intramuscular depot medroxyprogesterone acetate (DMPA-IM) to self-administered subcutaneous DMPA (DMPA-SC) in the context of the COVID-19 pandemic.

Methods: We conducted interviews with women in California and Washington about their experiences with self-administered DMPA-SC. We interviewed women after their first or second self-administered DMPA-SC injection and conducted follow-up interviews after their third or fourth injection. We performed both thematic and descriptive content analyses.

Results: We completed 29 interviews with 15 women. Most participants (n = 10) were between the ages of 20 and 39 and the majority (n = 12) used DMPA primarily for contraception. Most (n = 13) described self-administered DMPA-SC as "very easy" or "somewhat easy" to use and reported greater convenience, decreased pain, fewer logistical and financial challenges, increased privacy, and improved comfort with injection compared to DMPA-IM. Participants identified difficulties obtaining DMPA-SC from pharmacies and safe needle disposal as barriers. Most (n = 13) would recommend DMPA-SC to a friend and desired to continue self-administration beyond the COVID-19 pandemic. Participants recommended counseling all patients about this option alongside other contraceptive methods, and offering clinician supervision, if desired.

Conclusion: Women who switched from in-clinic DMPA-IM to self-administered DMPA-SC during the COVID-19 pandemic preferred the latter and intended to continue self-administration. Self-administration of DMPA-SC should be routinely offered and easily accessible to patients.

Introduction: Financial costs remain one of the greatest barriers to abortion, leading to delays in care and preventing some from getting a desired abortion. Medication abortion is available through in-person facilities and telehealth services. However, whether telehealth offers a more affordable option has not been well-documented.

Methods: We used Advancing New Standards in Reproductive Health (ANSIRH)'s Abortion Facility Database, which includes data on all publicly advertising abortion facilities and is updated annually. We describe facility out-of-pocket prices for medication abortion in 2021, 2022, and 2023, comparing in-person and telehealth provided by brick-and-mortar and virtual clinics, and by whether states allowed Medicaid coverage for abortion.

Results: The national median price for medication abortion remained consistent at $568 in 2021 and $563 in 2023. However, medications provided by virtual clinics were notably lower in price than in-person care and this difference widened over time. The median cost of a medication abortion offered in-person increased from $580 in 2021 to $600 by 2023, while the median price of a medication abortion offered by virtual clinics decreased from $239 in 2021 to $150 in 2023. Among virtual clinics, few (7%) accepted Medicaid. Median prices in states that accept Medicaid were generally higher than in states that did not.

Discussion: Medication abortion is offered at substantially lower prices by virtual clinics. However, not being able to use Medicaid or other insurance may make telehealth cost-prohibitive for some people, even if prices are lower. Additionally, many states do not allow telehealth for abortion, deepening inequities in healthcare.

Introduction: Intimate partner violence (IPV) involves an individual committing acts intended to harm or intimidate a current or former romantic partner. The COVID-19 pandemic and subsequent stay-at-home orders often trapped victims with perpetrators and intensified IPV. Although sexual and gender diverse people disproportionately experience IPV compared to cisgender, heterosexual people, their experiences are not well documented in the Canadian context. This study aimed to explore the experiences of Two-Spirit, lesbian, gay, bisexual, transgender, queer, intersex, asexual, and other sexual and gender diverse (2S/LGBTQIA+) people with IPV in Ontario and how the COVID-19 pandemic affected their IPV experiences.

Methods: We conducted in-depth, semi-structured interviews with self-identified 2S/LGBTQIA+ people who experienced IPV on/after March 15, 2020. We audio-recorded and transcribed all interviews and coded the transcripts for content and themes using inductive and deductive techniques.

Results: Our 20 participants experienced physical, psychological, sexual, and financial abuse. Technology-facilitated violence extended abuse geographically and temporally. IPV experiences were associated with negative mental health outcomes that were intensified by the COVID-19 pandemic. Participants struggled to see themselves as legitimate victims of IPV. Although participants regretted being victims of violence, many saw their abusive relationship(s) as a learning experience to inform future relationships.

Discussion: Our findings suggest that 2S/LGBTQIA+ people may experience unique forms of identity abuse and may have difficulty recognizing their IPV experiences as abuse. Ensuring that comprehensive sexual health education is trauma-informed, anti-oppressive, and includes information about healthy relationship dynamics, 2S/LGBTQIA+ relationships, and IPV is critical.