Debra B. Stulberg

Abortion Provision Among Practicing Obstetrician-Gynecologists

OBJECTIVE: To estimate prevalence and correlates of abortion provision among practicing obstetrician–gynecologists (ob-gyns) in the United States. METHODS: We conducted a national probability sample mail survey of 1,800 practicing ob-gyns. Key variables included whether respondents ever encountered patients seeking abortions in their practice and whether they provided abortion services. Correlates of providing abortion included physician demographic characteristics, religious affiliation, religiosity, and the religious affiliation of the facility in which a physician primarily practices. RESULTS: Among practicing ob-gyns, 97% encountered patients seeking abortions, whereas 14% performed them. Female physicians were more likely to provide abortions than were male (18.6% compared with 10.6%, adjusted odds ratio 2.54, 95% confidence interval 1.57–4.08), as were those in the youngest age group, those in the Northeast or West, those in highly urban postal codes, and those who identify as being Jewish. Catholics, Evangelical Protestants, non-Evangelical Protestants, and physicians with high religious motivation were less likely to provide abortions. CONCLUSION: The proportion of U.S. ob-gyns who provide abortions may be lower than estimated in previous research. Access to abortion remains limited by the willingness of physicians to provide abortion services, particularly in rural communities and in the South and Midwest. LEVEL OF EVIDENCE: II

Ectopic Pregnancy Rates in the Medicaid Population

OBJECTIVE The Centers for Disease Control and Prevention last estimated a national ectopic pregnancy rate in 1992, when it was 1.97% of all reported pregnancies. Since then rates have been reported among privately insured women and regional health care provider populations, ranging from 1.6-2.45%. This study assessed the rate of ectopic pregnancy among Medicaid beneficiaries (New York, California, and Illinois, 2000-03), a previously unstudied population. STUDY DESIGN We identified Medicaid administrative claims records for inpatient and outpatient encounters with a principal International Classification of Diseases 9th Revision diagnosis code for ectopic pregnancy. We calculated the ectopic pregnancy rate among female beneficiaries aged 15-44 as the number of ectopic pregnancies divided by the number of total pregnancies, which included spontaneous abortions, induced abortions, ectopic pregnancies, and all births. We used Poisson regression to assess the risk of ectopic pregnancy by age and race. RESULTS Four-year Medicaid ectopic pregnancy rates were 2.38% of pregnancies in New York, 2.07% in California, and 2.43% in Illinois. Risk was higher among black women compared with whites in all states (relative risk, 1.26; 95% confidence interval, 1.25-1.28; P < .0001), and among older women compared with younger women (trend for age, P < .001). CONCLUSION Medicaid beneficiaries in these 3 states experienced higher rates of ectopic pregnancy than reported for privately insured women nationwide in the same years. Relying on private insurance databases may underestimate ectopic pregnancys burden in the United States population. Furthermore, within this low-income population racial disparities exist.

Conflicts in Care for Obstetric Complications in Catholic Hospitals

Background: A recent national survey revealed that over half of obstetrician-gynecologists working in Catholic hospitals have conflicts with religious policies, but the survey did not elucidate the nature of the conflicts. Our qualitative study examines the nature of physician conflicts with religious policies governing obstetrician-gynecologist (ob-gyn) care. Results related to restrictions on the management of obstetric complications are reported here. Methods: In-depth interviews lasting about one hour were conducted with obstetrician-gynecologists throughout the United States. Questions focused on physicians’ general satisfaction with their hospital work settings and specific experiences with religious doctrine-based ob-gyn policies in the various hospitals where they have worked. Results: Conflicts reported here include cases in which Catholic hospital religious policy (Ethical and Religious Directives for Catholic Health Care Services) impacted physicians’ abilities to offer treatment to women experiencing certain obstetric emergencies, such as pregnancy-related health problems, molar pregnancy, miscarriage, or previable premature rupture of membranes (PPROM), because hospital authorities perceived treatment as equivalent to a prohibited abortion. Physicians were contractually obligated to follow doctrine-based policies while practicing in these Catholic hospitals. Conclusions: For some physicians, their hospitals prohibition on abortion initially seemed congruent with their own principles, but when applied to cases in which patients were already losing a desired pregnancy and/or the patients health was at risk, some physicians found the institutional restrictions on care to be unacceptable.

Obstetrician–gynecologists, religious institutions, and conflicts regarding patient care policies

OBJECTIVE The purpose of this study was to assess how common it is for obstetrician-gynecologists who work in religiously affiliated hospitals or practices to experience conflict with those institutions over religiously based policies for patient care and to identify the proportion of obstetrician-gynecologists who report that their hospitals restrict their options for the treatment of ectopic pregnancy. STUDY DESIGN We mailed a survey to a nationally representative sample of 1800 practicing obstetrician-gynecologists. RESULTS The response rate was 66%. Among obstetrician-gynecologists who practice in religiously affiliated institutions, 37% have had a conflict with their institution over religiously based policies. These conflicts are most common in Catholic institutions (52%; adjusted odds ratio, 8.7; 95% confidence interval, 1.7-46.2). Few reported that their options for treating ectopic pregnancy are limited by their hospitals (2.5% at non-Catholic institutions vs 5.5% at Catholic institutions; P = .07). CONCLUSION Many obstetrician-gynecologists who practice in religiously affiliated institutions have had conflicts over religiously based policies. The effects of these conflicts on patient care and outcomes are an important area for future research.

Perceptions of a reproductive health self-assessment tool (RH-SAT) in an urban community health center.

OBJECTIVE Physicians face barriers to incorporating recommended contraceptive and preconception health services, including reproductive life plans (RLPs), into primary care. With promising findings from early studies of RLPs, we examined the impact of a novel reproductive health self-assessment tool (RH-SAT) on reproductive health counseling. METHODS We created the RH-SAT for an urban community health center population and trained providers on preconception and contraceptive guidelines. Semi-structured interviews were conducted to assess perceptions of the tool with 22 patients and with all 15 providers at the clinic. Transcripts were thematically analyzed using a grounded theoretical approach. RESULTS Patients and providers reported the RH-SAT presented new and thought-provoking material that promoted patient participation and facilitated counseling. CONCLUSION This RH-SAT is acceptable and useful to patients and providers in an underserved urban health center. In accordance with Medical Communication Alignment Theory (MCAT), increased patient participation in reproductive health discussions may alert providers to patient interest in these topics. PRACTICE IMPLICATIONS This study provides preliminary evidence that the RH-SAT can help overcome barriers to reproductive health counseling in primary care. Providers may wish to incorporate tools into their practice to improve communication with patients about their reproductive health goals.

Ectopic pregnancy rates and racial disparities in the Medicaid population, 2004–2008

OBJECTIVE To assess 2004-2008 ectopic pregnancy rates among Medicaid recipients in 14 states and 2000-2008 time trends in three states and to identify differences in rate by race/ethnicity. DESIGN Secondary analysis of Medicaid administrative claims data. SETTING Not applicable. PATIENT(S) Women ages 15-44 enrolled in Medicaid in Arizona, California, Colorado, Florida, Illinois, Indiana, Iowa, Louisiana, Massachusetts, Michigan, Minnesota, Mississippi, New York, or Texas in 2004-2008 (n = 19,135,106) and in California, Illinois, and New York in 2000-2003. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Number of ectopic pregnancies divided by the number of total pregnancies (spontaneous abortions, induced abortions, ectopic pregnancies, and all births). RESULT(S) The 2004-2008 Medicaid ectopic pregnancy rate for all 14 states combined was 1.40% of all reported pregnancies. Adjusted for age, the rate was 1.47%. Ectopic pregnancy incidence was 2.3 per 1,000 woman-years. In states for which longer term data were available (California, Illinois, and New York), the rate declined significantly in 2000-2008. In all 14 states, black women were more likely to experience an ectopic pregnancy compared with whites (relative risk, 1.46; 95% confidence interval, 1.45-1.47). CONCLUSION(S) Ectopic pregnancy remains an important health risk for women enrolled in Medicaid. Black women are at consistently higher risk than whites.

Perceived Benefits and Barriers to Family Planning Education among Third Year Medical Students

Abstract Purpose: The purpose of the current study is to explore third- year medical students’ interest in learning about family planning, exposure to family planning (contraception and abortion) and perceived barriers and benefits to family planning education in their obstetrics and gynecology rotation. Method: We conducted four focus groups with 27 third-year medical students near the end of their rotation in obstetrics and gynecology. Results: Students desired education in family planning but perceived limited exposure during their rotation. Most students were aware of abortion but lacked factual information and abortion procedural skills. They felt systemic and faculty-related barriers contributed to limited exposure. Students discussed issues such as lack of time for coverage of contraception and abortion in the curricula and rotation itself. Perceived benefits of clinical instruction in family planning included increased knowledge of contraceptive management and abortion the ability to care for and relate to patients, opportunity for values clarification, and positive changes in attitudes towards family planning. Conclusions: Medical students who desire full education in family planning during their obstetrics and gynecology rotation may face barriers to obtaining that education. Given that many medical students will eventually care for reproductive-age women, greater promotion of opportunities for exposure to family planning within obstetrics and gynecology rotations is warranted.

The Research Consortium on Religious Healthcare Institutions: studying the impact of religious restrictions on women's reproductive health

Catholic hospitals and other religious institutions are a large and growing part of the US health care system. They have specific policies restricting reproductive health care. Despite increased public attention in the media to women denied necessary pregnancy-related care at Catholic hospitals, research on the effects of religious restrictions remains limited. This article summarizes research priorities as generated by 80 attendees at the inaugural meeting of the Research Consortium on Religious Healthcare Institutions. Such research is need to understand the impact of religious health system ownership on womens health.

Referrals for Services Prohibited In Catholic Health Care Facilities.

CONTEXT Catholic hospitals control a growing share of health care in the United States and prohibit many common reproductive services, including ones related to sterilization, contraception, abortion and fertility. Professional ethics guidelines recommend that clinicians who deny patients reproductive services for moral or religious reasons provide a timely referral to prevent patient harm. Referral practices in Catholic hospitals, however, have not been explored. METHODS Twenty-seven obstetrician-gynecologists who were currently working or had worked in Catholic facilities participated in semistructured interviews in 2011-2012. Interviews explored their experiences with and perspectives on referral practices at Catholic hospitals. The sample was religiously and geographically diverse. Referral-related themes were identified in interview transcripts using qualitative analysis. RESULTS Obstetrician-gynecologists reported a range of practices and attitudes in regard to referrals for prohibited services. In some Catholic hospitals, physicians reported that administrators and ethicists encouraged or tolerated the provision of referrals. In others, hospital authorities actively discouraged referrals, or physicians kept referrals hidden. Patients in need of referrals for abortion were given less support than those seeking referrals for other prohibited services. Physicians received mixed messages when hospital leaders wished to retain services for financial reasons, rather than have staff refer patients elsewhere. Respondents felt referrals were not always sufficient to meet the needs of low-income patients or those with urgent medical conditions. CONCLUSIONS Some Catholic hospitals make it difficult for obstetrician-gynecologists to provide referrals for comprehensive reproductive services.

Ectopic pregnancy morbidity and mortality in low-income women, 2004–2008

STUDY QUESTION Does the risk of adverse outcomes at the time of ectopic pregnancy vary by race/ethnicity among women receiving Medicaid, the public health insurance program for low-income people in the USA? SUMMARY ANSWER Among Medicaid beneficiaries with ectopic pregnancy, 11% experienced at least one complication, and women from all racial/ethnic minority groups were significantly more likely than whites to experience complications. WHAT IS KNOWN ALREADY In this population of Medicaid recipients, African American women are significantly more likely than whites to experience ectopic pregnancy, but the risk of adverse outcomes has not previously been assessed. STUDY DESIGN, SIZE, AND DURATION We conducted a cross-sectional observational study of all women (n = 19 135 106) ages 15-44 enrolled in Medicaid for any amount of time during 2004-2008 who lived in one of the following 14 US states: Arizona; California; Colorado; Florida; Illinois; Indiana; Iowa; Louisiana; Massachusetts; Michigan; Minnesota; Mississippi; New York; and Texas. PARTICIPANTS/MATERIALS, SETTINGS, METHODS We analyzed Medicaid claims records for inpatient and outpatient encounters and identified ectopic pregnancies with a principal diagnosis code for ectopic pregnancy from 2004-2008. We calculated the ectopic pregnancy complication rate as the number of ectopic pregnancies with at least one complication (blood transfusion, hysterectomy, any sterilization, or length-of-stay (LOS) > 2 days) divided by the total number of ectopic pregnancies. We used Poisson regression to assess the risk of ectopic pregnancy complication by race/ethnicity. Secondary outcomes were each individual complication, and ectopic pregnancy-related death. We calculated the ectopic pregnancy mortality ratio as the number of deaths divided by live births. MAIN RESULTS AND THE ROLE OF CHANCE Ectopic pregnancy-associated complications occurred in 11% of cases. Controlling for age and state, the risk of any complication was significantly higher among women who were black (incidence risk ratio [IRR] 1.47, 95% CI 1.43-1.53, P < 0.0001), Hispanic (IRR 1.16, 95% CI 1.12-1.21, P < 0.0001), Asian (IRR 1.34, 95% CI 1.24-1.45, P < 0.0001), American Indian/Alaskan Native (IRR 1.34 95% CI 1.16-1.55, P < 0.0001), and Native Hawaiian/Pacific Islander (IRR 1.61, 95% CI 1.39-1.87, P < 0.0001) compared with white women. The ectopic pregnancy mortality ratio was 0.48 per 100 000 live births, similar to that reported in previous US surveillance. LIMITATIONS, REASONS FOR CAUTION This is a secondary analysis of insurance claims. WIDER IMPLICATIONS OF THE FINDINGS Among women at higher baseline risk of pregnancy complications due to their economic status, women from racial/ethnic minority groups face an additional risk of ectopic pregnancy adverse outcomes compared with whites. Systematic changes to reduce racial disparities are an essential part of improving maternal health in the USA. STUDY FUNDING/COMPETING INTERESTS The Eunice Kennedy Shriver National Institute of Child Health and Human Development (1 K08 HD060663 to D.B.S.). The authors report no conflict of interest. TRIAL REGISTRATION NUMBER Not applicable.