Perspectives on Sexual and Reproductive Health最新文献

Introduction: In Georgia, maternal mortality is relatively high, and Black women are three times as likely to die from pregnancy-related causes as white women. Doulas can improve perinatal health and reduce disparities, but doula accessibility in Georgia is unclear.

Methods: This community-engaged mixed methods study surveyed and interviewed 17 doulas in Georgia. Surveys included structured questions on demographics, businesses, clientele, training, and challenges; we analyzed them using descriptive statistics. In-depth interviews included open-ended questions on doula care benefits, building their businesses, and improving access to doula care. We analyzed the content of transcripts using coding and memoing.

Results: Our diverse doula participants described providing life-saving services including education, referral to care, and patient advocacy. Yet they described numerous challenges to providing care and building their businesses. Almost all participants reported having fewer than their ideal number of clients and all reported being insufficiently paid for their services. Although training, mentoring, and networking help build their businesses, many doulas want to serve Black women, transgender men, gender non-binary individuals, and families living on lower incomes. Participants suggested Medicaid reimbursement and community health worker models as potential interventions for increasing equitable doula care access.

Discussion: Doulas can improve perinatal health outcomes and are urgently needed. Yet they face challenges in building businesses and finding clientele, especially from communities and groups at highest risk of negative outcomes during pregnancy, childbirth, and the postpartum period. Identifying avenues for supporting publicly-funded reimbursement, expanding equity-focused doula training, and fostering stronger doula networks with mentorship appears warranted.

Introduction: Agency in contraceptive decision-making is an essential aspect of reproductive autonomy. We conducted qualitative research to investigate what agency means to patients seeking contraceptive care to inform the development of a validated measure of this construct.

Methodology: We held four focus group discussions and seven interviews with sexually-active individuals assigned female at birth, ages 16-29 years, recruited from reproductive health clinics in Northern California. We explored experiences in contraceptive decision-making during the clinic visit. We coded data in ATLAS.ti and by hand, compared codes across three coders, and used thematic analysis to identify salient themes.

Results: The sample mean age was 21 years, with 17% of participants identifying as Asian, 23% as Black, 27% as Latinx, 17% as Multiracial/other, and 27% as white. Overall, participants reported active and engaged decision-making in their recent contraceptive visit but noted experiences that had undermined their agency in the past. They described how non-judgmental care allowed them to communicate openly, affirming their ability to make their own decisions. However, several mentioned how unexpected contraceptive side effects after the visit had reduced their sense of agency over their decision in retrospect. Several participants, including those who identified as Black, Latinx, and/or Asian, described prior experiences where pressure to use a contraceptive method had undermined their agency and where they had switched providers to regain agency over their contraceptive decisions.

Discussion: Most participants were aware of their agency during contraceptive visits and how it varied in different experiences with providers and the healthcare system. Patient perspectives can help to inform measurement development and ultimately the delivery of care that supports contraceptive agency.

Background: As a result of the June 2022 decision of the United States (US) Supreme Court, as many as 24 states have, or are expected to, ban or severely restrict abortion. We provide baseline information about abortion patients living in different state environments prior to this decision.

Methods: We obtained surveys from 6674 women, transgender men, and other pregnancy capable individuals accessing abortion care at 56 facilities across the US between June 2021 and July 2022. The final analytic sample uses information from 5930 abortion patients to compare the demographic and situational profiles of those living in the 24 states likely to ban abortion (restricted) to those living in states where it is likely to remain legal (protected).

Results: Compared to respondents who lived in protected states, abortion patients in restricted states were more likely to be Black (39% vs. 30%) or white (35% vs. 28%) and less likely to be Latinx (18% vs. 32%). Respondents in restricted states were more likely to be paying out-of-pocket for care (87% vs. 42%), be relying on financial assistance (22% vs. 11%), and indicate that it was difficult to pay for the abortion (54% vs. 28%). Twelve percent of respondents who lived in a restricted state crossed state lines for care and the majority (59%) was going to another restricted state.

Discussion: Prior to June 2022, abortion patients in restricted states encountered more situational and financial barriers compared to those in protected states. These barriers have undoubtedly been exacerbated by abortion bans.

Introduction: The initial stages of the COVID-19 pandemic affected abortion care in the United States (US) in myriad ways. While research has documented systems-level pandemic-related impacts on abortion access and care delivery little information exists about the experiences of abortion seekers during this period. We sought to document the effects of COVID-19 pandemic restrictions US abortion seekers by analyzing posts on Reddit, a popular social media website.

Methods: We compiled and coded 528 anonymous posts on the abortion subreddit from 3/20/2020 to 4/12/2020 and applied inductive qualitative analytic techniques to identify themes.

Results: We identified four primary themes. First, posters reported several COVID-19-related barriers to abortion services: reduced in-person access due to clinic closures, mail delivery delays of abortion medications, and pandemic-related financial barriers to both self-managed and in-clinic abortion. The second theme encompassed quarantine-driven privacy challenges, primarily challenges with concealing an abortion from household members. Third, posters detailed how the pandemic constrained their pregnancy decision making, including time pressure from impending clinic closures. Finally, posters reported COVID-19-related changes to service delivery that negatively affected their abortion experiences, for example being unable to bring a support person into the clinic due to pandemic visitor restrictions.

Discussion: This analysis of real-time social media posts reveals multiple ways that the COVID-19 pandemic limited abortion access in the US and affected abortion seekers' decisions and experiences. Findings shed light on the consequences of sudden changes, whether pandemic or policy related, on abortion service delivery.

Context: Removing the prescription requirement and making oral contraceptive pills available over the counter (OTC) could increase contraceptive access in the United States. Despite current efforts to make a progestin-only pill (POP) available OTC, there are no qualitative data exploring the experiences of POP users and their perspectives on making POPs available OTC.

Methods: We conducted six online, asynchronous focus group discussions with 36 POP users between July and November 2020. We stratified focus group discussion placement based on three reasons for POP use: breastfeeding, having a contraindication to estrogen (for a reason other than breastfeeding), and for any other reason. We thematically analyzed these data using inductive and deductive coding.

Results: The majority of participants described their overall POP experience as positive, mostly because they experienced minor or no side effects and thought the pill was effective. Participants overwhelmingly supported OTC availability of POPs and expressed interest in purchasing an OTC POP. Over one-third of participants had very limited knowledge or held inaccurate assumptions about POPs before they started using this method and many stressed the need to disseminate accurate information and resources about POPs to the public.

Conclusions: Most focus group discussion participants were satisfied with POPs and supported OTC access. While misconceptions and concerns about POPs should be addressed, an OTC POP has the potential to be a safe, effective, and convenient contraceptive option in the United States.

Context: A growing body of evidence supports over-the-counter access to oral contraceptives in the United States. An important consideration for over-the-counter approval is consumers' ability to understand key package label messages related to safety and effectiveness without clinician involvement. We developed a prototype over-the-counter Drug Facts Label for a combined oral contraceptive pill and conducted a pilot label comprehension study to evaluate consumer understanding of key messages for use.

Methods: In November-December 2020, we conducted interviews with 163 adults and teens in the United States who were aged 12-49 years and identified as female or another gender but had a uterus and the ability to become pregnant. We developed 11 primary endpoints based on assessment of clinical risks that could occur if consumers fail to heed them, including messages about contraindications and directions for use; 11 secondary endpoints represented additional important information but with lower potential for clinical consequences if not understood. We evaluated endpoint comprehension by computing frequencies, percentages, and 2-sided Exact (Clopper-Pearson) 95% confidence intervals for observed proportions.

Results: Ten of the 11 primary endpoints and 10 of the 11 secondary endpoints were each understood by ≥95% of participants. The remaining primary endpoint on use with prior blood clots was understood by 89% of participants. The remaining secondary endpoint on the product being designed for "people who have the ability to become pregnant" was understood by 83% of participants.

Conclusion: Participants understood the key label information required for safe and effective combined oral contraceptive use without clinician involvement.

Background: The number of women using long-acting reversible contraception (LARC)-intrauterine devices (IUDs) and implants-is increasing and 14% of contraceptive users in the United States adopt LARC. We examined correlates of LARC never-use in a population-based survey of reproductive-aged women in Ohio.

Methods: We analyzed data from the 2018-19 Ohio Survey of Women. We examined the prevalence of LARC never-use and reasons for never-use among ever users of contraception (N = 2388). Using Poisson regression to generate prevalence ratios (PRs), we examined associations between selected correlates (demographic factors, healthcare access/quality measures, and religious/political views) and LARC never-use.

Results: Most Ohio women (74%) had never used LARC. Commonly reported reasons for not using an IUD or an implant were preferring a different method (46% and 45%, respectively), not wanting an object inside their body (45% and 43%), side effect concerns (39% and 33%), insertion/removal concerns (31% and 25%), and unfamiliarity (13% and 20%). Conservative political views (PR: 1.12, 95% confidence interval [CI]: 1.04-1.22), pro-life affiliation (PR: 1.11, 95% CI: 1.02-1.20), placing high importance on religion in daily life (PR: 1.15, 95% CI: 1.06-1.26), and being non-Hispanic white as compared to non-Hispanic Black (PR: 1.20, 95% CI: 1.02-1.41) were significantly associated with LARC never-use. Findings were generally similar for models analyzing IUD and implant never-use separately.

Conclusions: Among ever-users of contraception, LARC never-use was associated with having conservative political views, being religious, and having a pro-life affiliation. Except for race/ethnicity, demographic and healthcare measures were not associated with LARC never-use among women in Ohio.

Background: Sexual and reproductive health services promote the ability of people to have safe, satisfying, non-coercive sexual experiences and make informed decisions about pregnancy. Stakeholder input is needed to understand barriers or facilitators to service access for autistic people, who report unmet needs.

Methods: We recruited 18 autistic people, 15 parents, and 15 service providers in the United States to participate in an interview and two surveys. Using their input, we created a conceptual model of sexual and reproductive health service needs, access barriers, and facilitators.

Results: Stakeholders rated a variety of sexual and reproductive health services as important for autistic people, including those with intellectual disability or minimal verbal language. Stakeholders identified barriers to sexual and reproductive health service utilization including lack of service availability, lack of service providers with autism or neurodiversity training, lack of accurate information about autism and sexuality, verbal and communication differences that are not accommodated by service providers, and socio-cultural attitudes about sexuality. Stakeholders identified facilitators to service access including person-centered, trauma-informed care, service accommodations such as clear and detailed expectations, and long-enough appointments. We created a conceptual model based on the social ecological model of health to organize these utilization factors and support future research, provider, and policy action. Stakeholders provided feedback and responded favorably on the model's accuracy, utility for spurring research, practice, and policy improvements, and application to diverse groups of autistic people.

Conclusions: The model shows the many feasible ways to support equitable access to services for autistic people.

Objectives: This exploratory study aimed to assess COVID-19-related changes in abortion service availability and use in Washington, DC, Maryland, and Virginia.

Design: Data came from a convenience sample of eight abortion clinics in this region. We implemented a cross-sectional survey and collected retrospective aggregate monthly abortion data overall and by facility type, abortion type, and patient characteristics for March 2019-August 2020. We evaluated changes in the distribution of the total number of patients for March-August in 2019 compared to March-August 2020. We also conducted segmented regression analyses and produced scatter plots of monthly abortion patients overall and by facility type, abortion type, and patient characteristics, with separate fitted regression lines from the segmented regression models for the pre- and during-COVID-19 periods.

Results: Five clinics reported a reduced number of appointments early in the pandemic while four reported increased call volume. There were declines in the monthly abortion trend at hospital-based clinics at the outset of the pandemic. Monthly number of medication abortions increased from March 2020 through August 2020 compared to pre-COVID-19 trends while instrumentation abortions 11 up to 19 weeks decreased. The share of abortions to Black individuals increased during the early phase of the pandemic, as did the monthly trend in abortions among this group. We also saw changes in payment type, with declines in patients paying out-of-pocket.

Conclusions: Results revealed differences in abortion services, numbers, and types during the early stages of the COVID-19 pandemic in Washington, DC, Maryland, and Virginia.

Objectives: To evaluate self-reported outcomes and serious adverse events following self-managed medication abortion using misoprostol alone provided from an online service.

Study design: We conducted a retrospective record review of self-managed abortion outcomes using misoprostol obtained from Aid Access, an online telemedicine organization serving United States (US) residents, between June 1, 2020, and June 30, 2020. The main outcomes were the proportion of people who reported ending their pregnancy without instrumentation intervention and the proportion who received treatment for serious adverse events.

Results: During the study period, 1016 people received prescriptions for misoprostol. We obtained follow-up information for 610 (60%) of whom 568 confirmed use of the medication and 42 confirmed non-use. When taking the medication, 96% were at or less than 10 weeks' gestation and 4% were more than 10 weeks. Overall, 88% (95% CI: 84.6-90.2) reported successfully ending their pregnancy without instrumentation intervention. Of the 568 who took the misoprostol, 12 (2%) reported experiencing one or more serious adverse events and 20 (4%) reported experiencing a symptom of a potential complication.

Conclusions: Self-managed medication abortion using misoprostol provided by an online telemedicine service has a high rate of effectiveness and a low rate of serious adverse events. Outcomes compare favorably to other service delivery models using a similar regimen. As mifepristone continues to be over-regulated and the 2022 US Supreme Court ruling allows states to severely restrict access to in-clinic abortion care, this regimen is a promising option for self-managed abortion in the US.