Amy Godecker

Union status marital history and female contraceptive sterilization in the United States.

CONTEXT Much of what is known about the choice of sterilization as a contraceptive method is based on data from married women or couples. Because of increasing rates of cohabitation, divorce and repartnering, however, the relationship context in which sterilization decisions are made has changed. METHODS The 1995 National Survey of Family Growth includes the complete birth and union histories of 10,277 white, black and Hispanic women. The distribution of union status and marital history at the time of tubal sterilization was estimated for these three racial and ethnic groups among the 799 women who had had a tubal ligation in 1990-1995 before age 40. Cox proportional hazard regression models were used to estimate the effects of union status and marital history on the risk of tubal sterilization. The analysis controlled for the womans age, parity, race and ethnicity education, region, experience of an unwanted birth and calendar period. RESULTS Among women who obtained a tubal sterilization, most whites (79%) and Hispanics (66%) were married when they had the operation, compared with only 36% of black women. At the time of their sterilization, 46% of black women had never been married. Among all women, regardless of race and ethnicity and net of all controls, the probability of tubal sterilization is about 25% lower for single, never-married women than for cohabiting or married women. Cohabitation does not reduce the likelihood in comparison to marriage, however. Higher rates of tubal sterilization among Hispanic women are accounted for by their higher parity at each age; differences in parity or marriage by race only partially account for the relatively higher rates of tubal sterilization among black women. CONCLUSIONS Because women currently spend greater proportions of their lives outside of marriage or in less-stable cohabiting partnerships than they did in the past, they are increasingly likely to make the decision to seek sterilization on their own. As a result, the gender gap in contraceptive sterilization will likely increase. The possibility of partnership change is an important consideration in choosing sterilization as a contraceptive method.

Women, men, and contraceptive sterilization

OBJECTIVE To review the social and behavior contexts of decisions about contraceptive sterilization and to analyze factors associated with sterilization choices. DESIGN Multinomial logit regression of sterilization. PATIENT(S) Various subsamples as appropriate to specific analyses drawn from the 10,847 women interviewed in the 1995 National Survey of Family Growth, and the 5,227 men interviewed in the National Survey of Families and Households. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Tubal sterilization and vasectomy. RESULT(S) Surprisingly high proportions of recent tubal sterilizations were performed on unmarried women: 1 in 3 overall, 1 in 5 among white non-Hispanic women, and 2 in 3 among black women. Sterilization choice among continuously married couples also revealed large differences by race and ethnicity. Parity at the time of the last wanted birth is a major factor affecting sterilization choices, although significant effects were found as well as for a number of other variables, including age differences between spouses, education, and religion. Compared with other regions, the ratio of tubal sterilizations to vasectomies is extremely low in the Western region of the United States. CONCLUSION(S) Analysis of sterilization decisions must be based on time since the completion of childbearing. The findings call attention to the need for measuring variables that mediate observed associations with sterilization outcomes.

Psychosocial Risk Screening during Pregnancy: Additional Risks Identified during a Second Interview

The Prenatal Risk Overview (PRO) screens for 13 psychosocial risk factors associated with poor birth outcomes. This study assessed the extent to which risk factors unreported during an intake interview were identified during a subsequent interview. A total of 708 pregnant women were screened and re-screened at three urban community health care centers between July 2007 and April 2010. Study participants were predominantly young (mean age 23.5 years), unmarried (75.1%) women of color (92.5%); 38.4% were foreign-born. The proportional increase in participants identified as being at risk for individual domains at the second interview ranged from 5.6% to 49.0% for the combined Moderate/High Risk classification and from 5.6% to 73.0% for the High Risk only classification. For women whose health and well-being are challenged by poverty, violence, social isolation, and other stressors, both initial screening and repeat screening offer opportunities to alleviate identified risks.

Addressing perinatal depression in a group of underserved urban women: a focus group study

BackgroundPerinatal mental health problems are common complications of pregnancy that can go undetected and untreated. Research indicated that mental health complications are more prevalent in women from disadvantaged communities, yet women from these communities often experience barriers to accessing treatments and interventions. Untreated depression during pregnancy can lead to poor self-care, increased substance abuse, poor obstetrical outcomes, developmental delay in children, and increased risk of postpartum depression. In this study we investigated the perceived perinatal mental health needs of our participants and they wanted to address their perceived needs.MethodsIn this qualitative study, we invited women who resided in an underserved, urban community who were pregnant or who delivered within the past year to participate in focus groups.ResultsThirty-seven women participated in seven focus groups. Thirteen themes emerged which were described in relation to mental health needs, help currently accessed and the type of support wanted. The themes included the various mental health needs including dealing with changing moods, depression, feelings of isolation, worrying and a sense of being burdened. Women described using a limited range of supports and help. Participants expressed a preference for mental health support that was empowerment focused in its orientation, including peer support. Women also described the compounding effect that social and economic stresses had on their mental health.ConclusionsParticipants wanted access to a greater range of supports for mental health than were currently available to them, including peer support, and wanted assistance in addressing social and economic needs. These findings offer a challenge to further broaden the types of services offered to women, and demonstrate that those services need to be responsive to the challenging contexts of women’s lives. Integrating women’s views and experiences into the development of services may help to overcome barriers to care.

Validity of the Prenatal Risk Overview for Detecting Drug Use Disorders in Pregnancy

OBJECTIVE To validate the Prenatal Risk Overview (PRO) drug use questions against a structured diagnostic interview among pregnant women. DESIGN AND SAMPLE Prenatal care patients were administered the PRO at intake and then asked to consent to a research diagnostic interview. Of 1,367 women asked to participate, 1,274 consented and 745 completed the study. MEASURES Three drug use items comprised one of 13 PRO psychosocial risk domains. The Structured Clinical Interview for DSM-IV (SCID) was used as the validation instrument. To assess criterion validity, the Moderate/High and High Risk classifications were cross-tabulated with SCID Drug Use Disorder diagnoses. RESULTS In response to the PRO, almost one third of participants (29.4%) reported drug use during the 12 months pre-pregnancy awareness and 11.0% reported use post-pregnancy awareness; 7.0% met SCID diagnostic criteria for Drug Abuse, Drug Dependence, or both, primarily for marijuana use. Drug Use Disorder sensitivity and specificity rates for the PRO Moderate/High Risk classifications were 88.5% and 74.3%, respectively, and for High Risk only, 78.8% and 87.3%. CONCLUSION The PRO yielded substantial self-reporting of drug use before and after pregnancy awareness with high sensitivity and specificity for detecting Drug Use Disorders. PRO results can inform decisions about appropriate clinical responses.

Nurse versus Community Health Worker Identification of Psychosocial Risks in Pregnancy through a Structured Interview

A structured psychosocial risk screening interview, the Prenatal Risk Overview, was administered to 733 women in prenatal care. Either a community health worker (CHW) or a registered nurse (RN) conducted the interview based on day of the week. A comparison of identified risk factors found no significant differences between study samples for six of 13 domains. For CHW interviews, significantly more participants were classified as Moderate/ High Risk for Depression, Lack of Telephone Access, Food Insecurity, and Housing Instability, and as High Risk for Lack of Social Support, Lack of Transportation Access, and Housing Instability. For RN interviews, significantly more participants were classified as High Risk for Alcohol Use. Community health workers successfully conducted psychosocial screening and elicited more self-reported risk than RNs, especially lack of basic needs. Comparing the hourly salary/ wage, the cost for CHWs was 56% lower than for RNs. Preliminary findings support use of paraprofessionals for structured screening interviews.

Racial and ethnic differences in patterns of long-acting reversible contraceptive use in the United States, 2011–2015

OBJECTIVE To investigate whether demographic, socioeconomic, and reproductive health characteristics affect long-acting reversible contraceptive (LARC) use differently by race-ethnicity. Results may inform the dialogue on racial pressure and bias in LARC promotion. STUDY DESIGN Data derived from the 2011-2013 and 2013-2015 National Surveys of Family Growth (NSFG). Our study sample included 9321 women aged 15-44. Logistic regression analyses predicted current LARC use (yes vs. no). We tested interaction terms between race-ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic) and covariates (for example, education, parity, poverty level) to explore whether their effects on LARC use vary by race-ethnicity. RESULTS In the race-interactions model, data did not show that low income and education predict LARC use more strongly among Black and Hispanic women than among White women. There was just one statistically significant race-interaction: experience of unintended pregnancy (p=.014). Among Whites and Hispanics, women who reported ever experiencing an unintended pregnancy had a higher predicted probability of LARC use than those who did not. On the other hand, among Black women, the experience of unintended pregnancy was not associated with a higher predicted probability of LARC use. CONCLUSIONS With the exception of the experience of unintended pregnancy, findings from this large, nationally representative sample of women suggest similar patterns in LARC use by race-ethnicity. IMPLICATIONS Results from this analysis of NSFG data do not provide evidence that observed differences in LARC use by race-ethnicity represent socioeconomic disparities, and may assuage some concerns about reproductive coercion among women of color. Nevertheless, it is absolutely critical that providers use patient-centered approaches for contraceptive counseling that promote womens autonomy in their reproductive health care decision-making.

Response to letter from Coronado-Montoya et al.

The Patient Health Questionnaire (PHQ)-9 is used widely in primary care and home visiting settings, but its validity had not been established for prenatal depression screening. We undertook our study to address this gap by validating, through accepted methods, the PHQ-9 to screen pregnant women for depression. The validation of this instrument adds to the toolbox for depression screening in prenatal care in the context of current depression screening guidelines and clinical practices. We believe our findings relative to identifying women at risk for depression with this screening instrument stand on their own, within the limitations we articulate. Based on the substantial evidence that both diagnosed depression and elevated depressive symptoms pose a risk to a healthy pregnancy and birth outcomes (Davalos et al. 2012; Alder et al. 2007), we believe that decisions regarding screening during pregnancy are more complex than the letter authors’ discussion acknowledges. Coronado-Montoya et al. believe that our study would have produced a lower number of women identified with major depressive disorder (MDD) through screening if we had excluded from the study women who had been treated or diagnosed with MDD. Their assumption that half of the women withMDD identified by our study would have already been identified is speculative and inconsistent with what is known about the underdiagnosis and undertreatment of depression in low-income, minority populations (Neighbors et al. 2007; US Department of Health and Human Services 2001) similar to our study population. Coronado-Montoya et al. also state that for a screening program to be successful, it must not only identify depressed individuals but also engage them in treatment and obtain positive treatment results. They further conclude that because we did not conduct a randomized control trial to assess whether screened women benefited more than unscreened women, our recommendation to use the PHQ-9 to screen for depression in pregnant women is premature and should be reconsidered. While we laud efforts to improve the research evidence linking screening to patient engagement and treatment outcomes, our intent was to test the PHQ-9 as a screening instrument, not as a stand-alone screening program. Reviews of screening in primary care (e.g., Gilbody et al. 2008 cited by the letter authors) that found that screening may lead to increased diagnoses and treatment but not improvement in depression outcomes raise questions about the efficacy of the treatment options available, not necessarily the efficacy of screening. The letter authors suggest that depression screening during pregnancy is not appropriate because it may identify patients whose symptoms are not obvious enough for them to seek help. The awareness of those symptoms through a systematic assessment may still be important for prenatal care providers because of possible increased risk for poor birth outcomes. Additionally, there are other reasons women may not seek help (Nadeem et al. 2009). Women like those in our sample—racial/ethnic minorities, young, unmarried, served through community health care centers—may not view their “symptoms” as a health problem to be resolved through treatment, but rather a natural reaction to the socioeconomic and other stressors they confront daily. Furthermore, based on our local focus group data (unpublished), many do not want psychotherapeutic or pharmacologic interventions; they want A. C. Sidebottom (*) Allina Health, 2925 Chicago Ave, Minneapolis, MN 55407-1321, USA e-mail: abbey.sidebottom@allina.com