Brittni N. Frederiksen

Unintended pregnancy and interpregnancy interval by maternal age, National Survey of Family Growth

BACKGROUND The relationship between unintended pregnancy and interpregnancy interval (IPI) across maternal age is not clear. METHODS Using data from the National Survey of Family Growth, we estimated the percentages of pregnancies that were unintended among IPI groups (<6, 6-11, 12-17, 18-23, 24+ months) by maternal age at last live birth (15-19, 20-24, 25-29, 30-44 years). RESULTS Approximately 40% of pregnancies were unintended and 36% followed an IPI<18 months. Within each maternal age group, the percentage of pregnancies that were unintended decreased as IPI increased. CONCLUSION Unintended pregnancies are associated with shorter IPI across the reproductive age spectrum.

Report of the Office of Population Affairs’ expert work group meeting on short birth spacing and adverse pregnancy outcomes: Methodological quality of existing studies and future directions for research

Abstract Background The World Health Organization (WHO) recommends that women wait at least 24 months after a livebirth before attempting a subsequent pregnancy to reduce the risk of adverse maternal, perinatal, and infant health outcomes. However, the applicability of the WHO recommendations for women in the United States is unclear, as breast feeding, nutrition, maternal age at first birth, and total fertility rate differs substantially between the United States and the low‐ and middle‐resource countries upon which most of the evidence is based. Methods To inform guideline development for birth spacing specific to women in the United States, the Office of Population Affairs (OPA) convened an expert work group meeting in Washington, DC, on 14‐15 September 2017 among reproductive, perinatal, paediatric, social, and public health epidemiologists; obstetrician‐gynaecologists; biostatisticians; and experts in evidence synthesis related to womens health. Results Presentations and discussion topics included the methodological quality of existing studies, evaluation of the evidence for causal effects of short interpregnancy intervals on adverse perinatal and maternal health outcomes, good practices for future research, and identification of research gaps and priorities for future work. Conclusions This report provides an overview of the presentations, discussions, and conclusions from the expert work group meeting.

Good practices for the design, analysis, and interpretation of observational studies on birth spacing and perinatal health outcomes

Abstract Background Meta‐analyses of observational studies have shown that women with a shorter interpregnancy interval (the time from delivery to start of a subsequent pregnancy) are more likely to experience adverse pregnancy outcomes, such as preterm delivery or small for gestational age birth, than women who space their births further apart. However, the studies used to inform these estimates have methodological shortcomings. Methods In this commentary, we summarise the discussions of an expert workgroup describing good practices for the design, analysis, and interpretation of observational studies of interpregnancy interval and adverse perinatal health outcomes. Results We argue that inferences drawn from research in this field will be improved by careful attention to elements such as: (a) refining the research question to clarify whether the goal is to estimate a causal effect vs describe patterns of association; (b) using directed acyclic graphs to represent potential causal networks and guide the analytic plan of studies seeking to estimate causal effects; (c) assessing how miscarriages and pregnancy terminations may have influenced interpregnancy interval classifications; (d) specifying how key factors such as previous pregnancy loss, pregnancy intention, and maternal socio‐economic position will be considered; and (e) examining if the association between interpregnancy interval and perinatal outcome differs by factors such as maternal age. Conclusion This commentary outlines the discussions of this recent expert workgroup, and describes several suggested principles for study design and analysis that could mitigate many potential sources of bias.

Use of Clinical Performance Measures for Contraceptive Care in Iowa 2013.

OBJECTIVES To assess feasibility of calculating clinical performance measures for contraceptive care for National Quality Forum submission: the percentage of women aged 15-44 years provided the following: (1) a most or moderately effective contraceptive method (MME) and (2) a long-acting reversible contraceptive (LARC) method. METHODS We used 2013 Iowa Department of Public Health (IDPH) Title X and Iowa Medicaid data. We stratified Title X data by age and Medicaid data by age and benefit type (family planning waiver (FPW) vs. general Medicaid), and examined variation by residence, public health region and health plan based on program interest. FINDINGS Among women attending IDPH Title X clinics in 2013 (N=11,584), 86% of women aged 15-20years and 83% of women aged 21-44years were provided MME; and 20% of women aged 15-20years and 20% of women aged 21-44years were provided LARC. Estimates varied across Title X subrecipient agencies, which receive federal funds from IDPH. Among Medicaid FPW clients (N=30,013), 79% of women aged 15-20years and 73% of women aged 21-44years were provided MME; and 12% of women aged 15-20years and 11% of women aged 21-44years were provided LARC. Among general Medicaid clients (N=14,737), 40% of women aged 15-20years and 28% of women aged 21-44years were provided MME; and 5% of women aged 15-20years and 5% of women aged 21-44years were provided LARC. CONCLUSION A high percentage of IDPH Title X and FPW clients were provided an MME method. No reporting entity had a LARC percentage less than 1%-2%. IMPLICATIONS Measure calculation using Title X and Medicaid data is feasible and can potentially be used to identify ways to increase access to contraceptive methods.

From theory to application: using performance measures for contraceptive care in the Title X family planning program

OBJECTIVE The objective was to describe a Performance Measure Learning Collaborative (PMLC) designed to help Title X family planning grantees use new clinical performance measures for contraceptive care. STUDY DESIGN Twelve Title X grantee-service site teams participated in an 8-month PMLC from November 2015 to June 2016; baseline was assessed in October 2015. Each team documented their selected best practices and strategies to improve performance, and calculated the contraceptive care performance measures at baseline and for each of the subsequent 8 months. RESULTS PMLC sites implemented a mix of best practices: (a) ensuring access to a broad range of methods (n=7 sites), (b) supporting women through client-centered counseling and reproductive life planning (n=8 sites), (c) developing systems for same-day provision of all methods (n=10 sites) and (d) utilizing diverse payment options to reduce cost as a barrier (n=4 sites). Ten sites (83%) observed an increase in the clinical performance measures focused on most and moderately effective methods (MME), with a median percent change of 6% for MME (from a median of 73% at baseline to 77% post-PMLC). CONCLUSION Evidence suggests that the PMLC model is an approach that can be used to improve the quality of contraceptive care offered to clients in some settings. Further replication of the PMLC among other groups and beyond the Title X network will help strengthen the current model through lessons learned. IMPLICATIONS Using the performance measures in the context of a learning collaborative may be a useful strategy for other programs (e.g., Federally Qualified Health Centers, Medicaid, private health plans) that provide contraceptive care. Expanded use of the measures may help increase access to contraceptive care to achieve national goals for family planning.

Providing quality family planning services to LGBTQIA individuals: a systematic review

OBJECTIVE Lesbian, gay, bisexual, transgender, queer/questioning, intersex and asexual (LGBTQIA) individuals have unique sexual and reproductive health needs; however, facilitators and barriers to optimal care are largely understudied. The objective of this study was to synthesize findings from a systematic review of the literature regarding the provision of quality family planning services to LGBTQIA clients to inform clinical and research strategies. STUDY DESIGN Sixteen electronic bibliographic databases (e.g., PubMed, PSYCinfo) were searched to identify articles published from January 1985 to April 2016 relevant to the analytic framework. RESULTS The search parameters identified 7193 abstracts; 19 descriptive studies met inclusion criteria. No studies assessed the impact of an intervention serving LGBTQIA clients on client experience, behavior or health outcomes. Two included studies focused on the perspectives of health care providers towards LGBTQIA clients. Of the 17 studies that documented client perspectives, 12 elucidated factors facilitating a clients ability to enter into care, and 13 examined client experience during care. Facilitators to care included access to a welcoming environment, clinicians knowledgeable about LGBTQIA needs and medical confidentiality. CONCLUSIONS This systematic review found a paucity of evidence on provision of quality family planning services to LGBTQIA clients. However, multiple contextual facilitators and barriers to family planning service provision were identified. Further research is needed to assess interventions designed to assist LGBTQIA clients in clinical settings, and to gain a better understanding of effective education for providers, needs of specific subgroups (e.g., asexual individuals) and the role of the clients partner during receipt of care.

Clinic-Based Programs to Prevent Repeat Teen Pregnancy: A Systematic Review

CONTEXT The purpose of this paper is to synthesize and evaluate the evidence on the effectiveness of repeat teen pregnancy prevention programs offered in clinical settings. EVIDENCE ACQUISITION Multiple databases were searched for peer-reviewed articles published from January 1985 to April 2016 that included key terms related to adolescent reproductive health services. Analysis of these studies occurred in 2017. Studies were excluded if they focused solely on sexually transmitted disease/HIV prevention services, or occurred outside of a clinic setting or the U.S., Canada, Europe, Australia, or New Zealand. Inclusion and exclusion criteria further narrowed the studies to those that included information on at least one short-term (e.g., increased knowledge); medium-term (e.g., increased contraceptive use); or long-term (e.g., decreased repeat teen pregnancy) outcome, or identified contextual barriers or facilitators for providing adolescent-focused family planning services. Standardized abstraction methods and tools were used to synthesize the evidence and assess its quality. Only studies of clinic-based programs focused on repeat teen pregnancy prevention were included in this review. EVIDENCE SYNTHESIS The search strategy identified 27,104 citations, 940 underwent full-text review, and 120 met the adolescent-focused family planning services inclusion criteria. Only five papers described clinic-based programs focused on repeat teen pregnancy prevention. Four studies found positive (n=2) or null (n=2) effects on repeat teen pregnancy prevention; an additional study described facilitators for helping teen mothers remain linked to services. CONCLUSIONS This review identified clinic-based repeat teen pregnancy prevention programs and few positively affect factors that may reduce repeat teen pregnancy. Access to immediate postpartum contraception or home visiting programs may be opportunities to meet adolescents where they are and reduce repeat teen pregnancy. THEME INFORMATION This article is part of a theme issue entitled Updating the Systematic Reviews Used to Develop the U.S. Recommendations for Providing Quality Family Planning Services, which is sponsored by the Office of Population Affairs, U.S. Department of Health and Human Services.

Contraceptive Counseling in Clinical Settings: An Updated Systematic Review

CONTEXT The objective of this systematic review was to update a prior review and summarize the evidence (newly identified and cumulative) on the impact of contraceptive counseling provided in clinical settings. EVIDENCE ACQUISITION Multiple databases, including PubMed, were searched during 2016-2017 for articles published from March 1, 2011, to November 30, 2016. EVIDENCE SYNTHESIS The search strategy identified 24,953 articles; ten studies met inclusion criteria. Two of three new studies that examined contraceptive counseling interventions (i.e., enhanced models to standard of care) among adolescents and young adults found a statistically significant positive impact on at least one outcome of interest. Five of seven new studies that examined contraceptive counseling, in general, or specific counseling interventions or aspects of counseling (e.g., personalization) among adults or mixed populations (adults and adolescents) found a statistically significant positive impact on at least one outcome of interest. In combination with the initial review, six of nine studies among adolescents and young adults and 16 of 23 studies among adults or mixed populations found a statistically significant positive impact of counseling on at least one outcome of interest. CONCLUSIONS Overall, evidence supports the utility of contraceptive counseling, in general, and specific interventions or aspects of counseling. Promising components of contraceptive counseling were identified. The following would strengthen the evidence base: improved documentation of counseling content and processes, increased attention to the relationships between client experiences and behavioral outcomes, and examining the comparative effectiveness of different counseling approaches to identify those that are most effective. THEME INFORMATION This article is part of a theme issue entitled Updating the Systematic Reviews Used to Develop the U.S. Recommendations for Providing Quality Family Planning Services, which is sponsored by the Office of Population Affairs, U.S. Department of Health and Human Services.

Impact of Contraceptive Education on Knowledge and Decision Making: An Updated Systematic Review

CONTEXT Educational interventions can help individuals increase their knowledge of available contraceptive methods, enabling them to make informed decisions and use contraception correctly. This review updates a previous review of contraceptive education. EVIDENCE ACQUISITION Multiple databases were searched for articles published March 2011-November 2016. Primary outcomes were knowledge, participation in and satisfaction/comfort with decision making, attitudes toward contraception, and selection of more effective methods. Secondary outcomes included contraceptive behaviors and pregnancy. Excluded articles described interventions that had no comparison group, could not be conducted feasibly in a clinic setting, or were conducted outside the U.S. or similar country. EVIDENCE SYNTHESIS A total of 24,953 articles were identified. Combined with the original review, 37 articles met inclusion criteria and described 31 studies implementing a range of educational approaches (interactive tools, written materials, audio/videotapes, and text messages), with and without healthcare provider feedback, for a total of 36 independent interventions. Of the 31 interventions for which knowledge was assessed, 28 had a positive effect. Fewer were assessed for their effect on attitudes toward contraception, selection of more effective methods, contraceptive behaviors, or pregnancy-although increased knowledge was found to mediate additional outcomes (positive attitudes toward contraception and contraceptive continuation). CONCLUSIONS This systematic review is consistent with evidence from the broader healthcare field in suggesting that a range of interventions can increase knowledge. Future studies should assess what aspects are most effective, the benefits of including provider feedback, and the extent to which educational interventions can facilitate behavior change and attainment of reproductive health goals. THEME INFORMATION This article is part of a theme issue entitled Updating the Systematic Reviews Used to Develop the U.S. Recommendations for Providing Quality Family Planning Services, which is sponsored by the Office of Population Affairs, U.S. Department of Health and Human Services.

Community Education and Engagement in Family Planning: Updated Systematic Review

CONTEXT Community education and engagement are important for informing family planning projects. The objective of this study was to update two prior systematic reviews assessing the impact of community education and engagement interventions on family planning outcomes. EVIDENCE ACQUISITION Sixteen electronic databases were searched for studies relevant to a priori determined inclusion/exclusion criteria in high development settings, published from March 2011 through April 2016, updating two reviews that included studies from 1985 through February 2011. EVIDENCE SYNTHESIS Nine relevant studies were included in this updated review related to community education, in addition to 17 from the prior review. No new community engagement studies met inclusion criteria, as occurred in the prior review. Of new studies, community education modalities included mass media, print/mail, web-based, text messaging, and interpersonal interventions. One study on mass media intervention demonstrated a positive impact on reducing teen and unintended pregnancies. Three of four studies on interpersonal interventions demonstrated positive impacts on medium-term family planning outcomes, such as contraception and condom use. Three new studies demonstrated mostly positive, but inconsistent, results on short-term family planning outcomes. CONCLUSIONS Findings from this systematic review update are in line with a previous review showing the positive impact of community education using traditional modalities on short-term family planning outcomes, identifying additional impacts on long-term outcomes, and highlighting new evidence for education using modern modalities, such as text messaging and web-based education. More research is necessary to provide a stronger evidence base for directing community education and engagement efforts in family planning contexts. THEME INFORMATION This article is part of a theme issue entitled Updating the Systematic Reviews Used to Develop the U.S. Recommendations for Providing Quality Family Planning Services, which is sponsored by the Office of Population Affairs, U.S. Department of Health and Human Services.