Womens Health Issues最新文献

Background: As more transgender adolescents and young adults seek gender-affirming care, questions persist about how their desire for potentially fertility-affecting treatment intersects with their fertility intentions.

Methods: We surveyed 125 individuals born with a uterus and ovaries, living in the United States, initially prescribed gender-affirming testosterone at or before age 18, about their interest in genetically related children and history of fertility preservation and fertility-affecting procedures.

Results: Twenty-two percent of respondents did not want children, and 47% wanted children but did not think a genetic relationship was important. Another 8% indicated having genetically related children was important and 17% indicated they did not know. Only 47% recalled counseling about fertility preservation. Those who might want genetically related children were less satisfied when they did not recall counseling (p = .001). Significantly more people in the group who might want genetically related children still had one or both ovaries (100% vs. 86%; p = .03), desired to carry a pregnancy in the future or were unsure (30% vs. 8%; p = .01), and either desired to use their eggs for genetically related children or were unsure (93% vs. 26%; p < .001).

Conclusions: More than one-half of individuals prescribed gender-affirming testosterone as adolescents had no interest in genetically related children. Those who were interested in genetically related children were more likely to have other fertility-preserving interests and behaviors, including potentially desiring a pregnancy and still having one or both ovaries. This finding suggests that fertility-related behaviors of individuals prescribed gender-affirming testosterone are in line with their stated goals.

Background: Guidelines recommend tailored reproductive health counseling for women with congenital heart defects (CHDs) beginning in adolescence, yet provider adherence to recommendations remains understudied, particularly outside specialized cardiac care settings.

Study design: We conducted a cross-sectional cohort study among women aged 19 to 38 with CHDs, identified from active population-based birth defects registries in three states. Participants completed surveys from 2016 to 2019, including questions about contraception, pregnancy counseling, concerns, and experiences. Multivariable Poisson regression, adjusted for sociodemographic and health characteristics, assessed associations between CHD severity, counseling, and reproductive health outcomes.

Results: Of 765 women, those with severe CHDs, compared with non-severe, were more likely to report receiving clinician counseling about safe contraceptive methods (44.0% and 13.7%; adjusted prevalence ratio [aPR] = 3.0; 95% confidence interval [95% CI] [2.2, 4.0]), pregnancy, (63.3% and 16.5%; aPR = 3.6; 95% CI [2.7, 4.6]), and pregnancy avoidance (32.0% and 6.4%; aPR = 4.3; 95% CI [2.9, 6.6]); be concerned about ability to have children (40.9% and 31.2%; aPR = 1.4; 95% CI [1.1, 1.8]), and delay/avoid pregnancy (26.6% and 10.7%; aPR = 2.2; 95% CI [1.5, 3.2]). No disparity was found in ever being pregnant (30.0% vs. 37.2%; aPR = 1.0; 95% CI [0.7, 1.2]). One-third of the respondents with any CHD reported concerns about their ability to have children (33.6%).

Conclusion: We found that only a minority of women with CHDs reported receiving counseling on safe contraception and pregnancy, and about a third reported concerns about their ability to have children. These findings highlight a gap between guideline recommendations and clinical practice, underscoring the need for improved reproductive health discussions for women with CHDs.

Background: New federal mandates require universal screening and referral for social determinants of health (SDOHs), and evidence exists supporting its integration into primary care practice. However, implementation in maternity care remains understudied and underfunded. To inform maternal health practice, we studied clinical stakeholders' perspectives on SDOH screening and referral knowledge, priority, challenges, and opportunities across four hospital-affiliated obstetrics and gynecology clinics in New Hampshire.

Methods: We conducted 15 semistructured interviews and four focus groups (with 20 total group participants) to explore clinical providers' and staff perspectives regarding the implementation of SDOH screening at their obstetrics clinics. We used the updated Consolidated Framework for Implementation Research to inform our interview and focus group guides. We identified our themes inductively using Practical Thematic Analysis.

Results: Participants represented nine different clinical and administrative roles. Four major themes culminated from the interviews and focus groups: 1) clinic staff identified clinic-specific workflows as critical to implementing the SDOH screening intervention; 2) clinical staff's workload and lack of training in SDOHs informed their level of commitment to SDOH screening and referral; 3) given many patients' extensive psychosocial needs, clinical staff wanted dedicated resources and time to respond to screening results; and 4) clinical staff perceived that SDOH screening impacts the patient experience, with the potential to decrease stigma depending on how screening results are discussed.

Conclusions: Despite unanimous support for addressing SDOHs within maternity care, participants perceived persistent challenges to effectively implementing SDOH screening and providing adequate referrals. They recommended that screening for SDOHs in vulnerable populations be accompanied by clear guidance and leadership, equitable distribution of resources and staff time between implementing clinics, and continuous quality improvement efforts.

Background: The association between economic insecurity and mental health among low-income pregnant people is understudied. We examined the relationship between economic insecurity and perinatal stress, anxiety, and depressive symptoms among a low-income, racially/ethnically diverse study population, and differentiated associations by nativity status.

Methods: We used cross-sectional data from the EMBRACE Study that enrolled Medi-Cal (California's Medicaid program) eligible pregnant people in the Central Valley region of California. Economic insecurity was assessed through measures of food insecurity, low financial well-being, inability to pay an emergency expense, inability to pay bills, fear of eviction, and history of homelessness. We examined the association of these measures with perceived stress (Perceived Stress Scale), generalized anxiety symptoms (Generalized Anxiety Disorder-7), and depressive symptoms (Patient Health Questionnaire-9), adjusting for age, relationship status, and education level. We also examined effect measure modification by nativity among the Latinx population. We report the estimated differences and 95% confidence intervals for each exposure and outcome.

Results: In our sample of 674 participants, we observed associations between economic insecurity and mental health. Among the 24 models, 15 showed medium to large effects (>0.35 standard deviation differences) and only three showed negligible effect sizes. Across all outcomes, we observed a stronger relationship between economic insecurity and mental health for U.S.-born Latinx people compared with their foreign-born (93% Mexico-born) counterparts.

Conclusion: We found low-income pregnant people experience significant economic insecurities that may impact mental health adversely. Programs that increase economic supports during pregnancy may serve as important maternal mental health interventions, especially among racial/ethnic minoritized groups.

Background: Women's smoking and cessation behaviors are influenced by various sex- and gender- (SaG) related factors; however, most smoking cessation programs that do not target pregnant women follow a gender-neutral approach. We aimed to systematically review the literature on smoking cessation programs for women outside reproductive contexts to assess their effectiveness and how they address SaG-related barriers.

Methods: We selected experimental studies published between June 1, 2009, and June 7, 2023, that describe smoking cessation interventions designed exclusively for women. Two independent reviewers extracted study characteristics, intervention effectiveness, strategies to address SaG-related factors, and the studies' approach to gender equity using the gender integration continuum. We searched multiple databases to comprehensively identify relevant studies for inclusion. The protocol was registered with PROSPERO #CRD42023429054.

Results: Twenty-five studies were selected and summarized using a narrative synthesis. Of these, nine (36%) found a greater reduction in smoking in the intervention group relative to the comparison group. Nine studies addressed women's concerns about post-cessation weight gain; however, in only one of these did the intervention group show a greater likelihood of quitting smoking relative to the comparison group. In contrast, three of four studies tailored for women facing socioeconomic disadvantage, and three of four studies designed for women with medical comorbidities, reported a greater reduction in smoking behaviors in the intervention relative to the comparison group. Ten studies relied solely on counseling and did not provide participants with smoking cessation pharmacotherapy. Overall, studies addressed individual and community-level barriers to quitting, including post-cessation weight gain, lack of social support, psychological distress, and cultural influences. All but one study avoided using harmful gender norms to promote cessation.

Conclusions: Strategies that address SaG-related barriers to quitting may improve cessation outcomes among women, particularly when tailored to meet the unique needs of specific groups such as those facing socioeconomic disadvantage. Future studies should combine best practices in smoking cessation treatment-behavioral counseling and pharmacotherapy-with new knowledge on how SaG factors influence motives for smoking and barriers to quitting. Such an approach could lead to more effective and equitable smoking cessation interventions for women.

Background: Created to protect patients from coercive sterilization, the federally mandated 30-day waiting period for patients with Medicaid desiring permanent contraception is a known barrier to permanent contraception fulfillment. Existing research does not explicitly explore how physicians interpret and operationalize the consent policy, counsel regarding the waiting period, or whether physicians believe the policy should be revised. The purpose of this paper is to better understand obstetrician-gynecologist (OB-GYN) feelings, thoughts, and counseling practices around the waiting period as key stakeholders in counseling and provision of permanent contraception care.

Basic procedures: We interviewed 81 postpartum people with a documented desire for permanent contraception and 61 OB-GYNs at four hospitals across the United States. Interviews were audio-recorded, transcribed, and analyzed using rapid qualitative analysis and thematic content analysis.

Main findings: Forty-seven physicians (70.2%) expressed negative feelings toward the Medicaid waiting period policy and 14 (20.9%) expressed neutral/mixed feelings. Physicians often viewed the Medicaid sterilization consent policy as inequitable and reported feeling that the waiting period hinders patient autonomy. Several physicians suggested that the waiting period needs revision. Physicians cited several barriers related to the implementation of the waiting period, including a lack of prenatal care or the conversation not being initiated. Physicians mentioned various approaches to counseling around the waiting period, either explicitly or inexplicitly explaining the policy. Last, physicians discussed differing interpretations around the waiting period policy.

Principal conclusions: Physicians in our sample largely do not favor the current Medicaid sterilization waiting period. However, physicians report varying approaches to clinical counseling as well as beliefs regarding policy revision. Revision to the policy should be informed by the lived experience and expertise of the various stakeholders, including patients, clinicians, and policymakers.

Objective: More than 40% of U.S. birthing people are covered by Medicaid. Accountable Care Organizations (ACOs) are increasingly common in state Medicaid programs and may influence maternal health, quality of care, and outcomes. However, there has been limited examination of how Medicaid ACOs operate in the context of perinatal care. Our objective was to explore how individuals in ACO leadership have approached program design to address maternal health and how these programs have shaped health care utilization and maternal health from the perspective of postpartum ACO beneficiaries and clinicians.

Methods: We conducted virtual semi-structured interviews with three key stakeholder groups in Massachusetts (ACO leaders, maternity care clinicians, and Medicaid ACO members who had given birth within the past 6-24 months) between November 2021 and May 2023. Purposive sampling aimed to achieve variation in geographic location (members and clinicians) and race/ethnicity (members). Interviews were recorded, professionally transcribed, and analyzed iteratively using thematic analysis.

Principal findings: Thirty-three interviews were conducted: four with ACO leaders, 15 with maternity care clinicians, and 14 with ACO members. Maternity care clinicians did not perceive that ACO implementation had substantially impacted perinatal health care. Interviews with ACO leadership suggested that the lack of perceived impact may be partially explained by competing priorities; the Massachusetts Medicaid ACOs generally did not focus on maternal health during the initial implementation period. Postpartum ACO members were largely unaware of ACOs.

Conclusions: Lack of explicit attention to the perinatal population in Medicaid financing and delivery system reforms may reduce the potential impact in improving outcomes.

Background: Persons with disabilities are at higher risk of experiencing intimate partner violence (IPV) during the perinatal period than persons without disabilities. Although screening for IPV during the perinatal period is recommended by many organizations, little is known about screening rates for IPV by disability status.

Methods: Our objective was to compare rates of IPV screening during the perinatal period among persons with and without disabilities in the United States. A cross-sectional sample of 43,837 respondents provided data on disability, including difficulty in vision, hearing, ambulation, cognition, communication, and self-care. We conducted a secondary analysis of nationally representative data from the 2018-2020 Pregnancy Risk Assessment Monitoring System.

Results: During pregnancy, respondents with disabilities had a lower odds of IPV screening as compared with respondents without disabilities (adjusted odds ratio .83, 95% confidence interval [.70, .99]). Despite similar screening rates in the 12 months before conception and postpartum among respondents with and without disabilities who attended health care visits, those with disabilities were less likely to receive pregnancy-related care during pregnancy (p < .0001) and in the postpartum period (p < .0001) and thus missed opportunities to be screened.

Conclusion: Our findings demonstrate a need for health care providers to collaborate with policy makers, disability advocates, and researchers to reduce the disparities people with disabilities face in accessing health care, including screening for IPV during the perinatal period. Such efforts are essential for maximizing the health and safety of pregnant persons and new parents with disabilities and their children during the perinatal period.