Elizabeth Janiak

Second trimester dilation and evacuation: a risk factor for preterm birth?

Objective:To evaluate whether second trimester pregnancy termination with dilation and evacuation (D&E) vs induction of labor (IOL) affects subsequent risk of preterm birth.Study Design:Our cohort was a retrospective cohort of women undergoing second trimester pregnancy termination for fetal anomalies, fetal death or previable premature rupture of membranes. We analyzed the rates of spontaneous delivery <37 weeks in the first pregnancy following the termination. We also compared preterm birth rates in our cohort with national averages and analyzed by the total number of prior procedures.Result:There were 173 women in our cohort. Women who had undergone a D&E (n=130) were less likely to have a subsequent preterm birth (6.9 vs 30.2%; P<0.01). This held true for a low risk subset without obstetric risk factors. There was no statistical difference in preterm birth rates for women who had undergone a D&E as compared with national averages, nor between the rates of preterm birth for women with 0, 1, 2 or 3 or more prior first or second trimester procedures.Conclusion:We did not find that D&E was a risk factor for preterm delivery when compared with women with a prior IOL or national rates.

Medical student intrauterine device knowledge and attitudes: an assessment of clerkship training.

BACKGROUND Studies demonstrate that many clinician populations have poor knowledge of and harbor negative attitudes towards intrauterine devices (IUDs). We set out to assess the impact of the clinical clerkship in obstetrics and gynecology on medical student IUD knowledge and attitudes. STUDY DESIGN In this prospective cohort study, students at seven diverse US medical schools were surveyed at the start and completion of their obstetrics and gynecology clinical clerkships regarding IUD exposure, knowledge and attitudes. Subject responses were compared pre- and postclerkship. RESULTS One hundred six students returned completed paired surveys (response rate 82%). The preclerkship mean knowledge percent correct (54%, SD 17%) increased significantly at postclerkship assessment (72%, SD 18%) (p<.0001). The mean attitudes score also increased significantly from pre- (34%, SD 31%) to postclerkship (59%, SD 26%) (p<.0001). CONCLUSIONS US medical student IUD knowledge and attitudes are significantly improved through the obstetrics and gynecology clerkship. However, significant gaps in knowledge persist postclerkship.

Advance notice of contraceptive availability at surgical abortion: a pilot randomised controlled trial

Background With advance notice about the availability and effectiveness of contraceptive methods, abortion patients have more time and information for decision-making. We assessed the impact of an informational telephone call prior to the surgical abortion visit on patient contraceptive knowledge. Methods This was a pilot randomised controlled trial. Prior to their abortion visit, participants were randomised to the intervention message, a standardised notification about the availability, effectiveness and safety of long-acting (LARC) and short-acting reversible contraception (SARC) on the day of the abortion, or to the control message, a reiteration of appointment logistics without information about contraception. At the visit, participants completed a pre-procedure survey to assess contraceptive knowledge and usefulness of the intervention. The primary outcome was knowledge of LARC availability immediately after surgical abortion. A secondary outcome was contraceptive method uptake. Results We enrolled 234 subjects. The pre-visit telephone notification improved knowledge that LARC is available immediately after surgical abortion (71.3% vs 50.9%, P<0.01). Participants in both study arms found the telephone notifications useful. Post-abortion contraceptive method choice did not differ between study arms. Conclusions Advance notice about contraception was acceptable to surgical abortion patients and improved their contraceptive knowledge. Trial registration number NCT02836561.

Women's decision making for postpartum sterilization: does the Medicaid waiting period add value?

OBJECTIVES Currently, patients with federally funded insurance are required to sign a sterilization consent form (SCF) at least 30 days prior to sterilization, while privately insured patients are not. Although this policy was designed to protect the reproductive rights of vulnerable populations, it has had the unintended effect of creating a disparity in access to an effective contraceptive method. Our qualitative study aims to clarify the decision-making process surrounding postpartum sterilization and assess if patients perceive that the SCF adds value. STUDY DESIGN We interviewed 25 women who underwent postpartum sterilization procedures, 10 with private insurance and 15 with Medicaid. Topics discussed included reproductive history, reason for choosing sterilization, decision-making timeline and value of the SCF. We transcribed and coded the interviews and identified themes. RESULTS Participant responses indicated that decision-making processes were similar between patients with private insurance and those with Medicaid. For most women, the decision to undergo sterilization took place over the course of their reproductive lives. Participants expressed that nonbiased provider counseling, autonomy and information from other women were helpful to their decision making. Most subjects felt that the SCF might benefit other women but did not/would not affect their own decision making. CONCLUSIONS We did not find evidence suggesting that women with private insurance and women with Medicaid should be subjected to disparate restrictions on sterilization based on differences in decision-making processes. Characteristics of the decision-making process that women value, which in this population did not include the SCF, should be prioritized. IMPLICATIONS Given the potential negative consequences associated with the SCF including its disproportionate burden on women of low socioeconomic status, the lack of value added to the decision-making process for postpartum sterilization reported by our participants provides further evidence for reevaluation of the policy.

Impact of a case management programme for women seeking later second-trimester abortion: the case of the Massachusetts Access Program

Objective The Massachusetts Access Program is a statewide, centralised referral and case management program created to address barriers to later second-trimester abortions. This study outlines the scope of, describes provider experiences with, and evaluates provider acceptability of the Program. Study design We invited physicians, nurses and staff working in hospitals within the later abortion provider referral network to participate in a mixed-methods study that included a web-based quantitative survey and/or a semi-structured qualitative interview. We used descriptive statistics to analyse survey data and inductive coding methods to analyse interview data. Results From 2007–2012, 15–28% of abortions performed in Massachusetts at 19 weeks or greater gestational age annually were scheduled through the Access Program. We received 16 completed surveys and conducted seven interviews with providers who routinely receive referrals for later abortions through the Program. Providers overall reported positive experiences with the Program and found it highly acceptable. They described that the transportation, accommodation and financial assistance enabled patients access to care. The specialised and updated knowledge of the Access Coordinator in regards to abortion care also allowed her to act as a resource for providers. Conclusions The Access Program, through its referral and case management network, was a valuable resource both to patients seeking later second-trimester abortions and providers involved in abortion care. It acts as one example of an effective, highly acceptable and potentially replicable intervention to reduce barriers to obtaining later second-trimester abortions.

Evolving State-Based Contraceptive and Abortion Policies

During the first few months of the Trump presidency, as in previous Republican administrations, there have been numerous restrictions, limitations, and debates regarding sexual and reproductive health. These have included the following: reinstating the Mexico City Policy, which prevents US federal foreign funding for nongovernmental organizations that provide counseling or referrals for abortion-related services1; provisions in the proposed American Health Care Act that would have excluded Planned Parenthood from Medicaid reimbursements, restricted access to plans that cover abortions, and eliminated essential health services such as maternal care2; and a congressional resolution allowing states the right to deny Title X federal family planning grant money to any organization that provides abortion services or is associated with a clinician or center that performs abortions.3 With Republican control of Congress and the White House, measures and attempts to limit access to selected sexual and reproductive health services will undoubtedly continue, reflecting the official party platform and long-established policy positions. Although federal policy debates surrounding family planning and basic preventive health services for women are integral in shaping the political climate and clinical care, state-based policies are equally important in defining both these debates and the ways in which individuals access and use contraception and abortion

High-risk sexual behaviors while on depot medroxyprogesterone acetate as compared to oral contraception

BackgroundDepot medroxyprogesterone acetate (DMPA) contraceptive use is associated with an increased risk for Chlamydia infection. However, prior studies inadequately account for potential differences in sexual behavior between users of DMPA and users of other contraceptive methods. In this study we compare sexual risk-taking behavior in women using DMPA to women using oral contraceptive pills (OCP) to assess risk of Chlamydia trachomatis infection.MethodsIn this cross-sectional study of 630 reproductive-aged women seeking routine gynecologic care (449 OCP and 181 DMPA users) sexual risk-taking was evaluated by use of the Safe Sex Behavior Questionnaire, a validated measure of sexual behaviors and attitudes. All women were screened for Chlamydia. Logistic regression estimated the association of contraceptive choice, sexual behaviors, and Chlamydia infection.ResultsOral contraceptive pill users differed from DMPA users in age, race, marital status, education level, and pregnancy history (p-values all <0.05). Oral contraceptive pill users had used their method of contraception for longer average duration (p < 0.01) and reported greater frequency of condom use (p < 0.01). Eleven (2.5%) OCP and 2 (1.1%) DMPA users had Chlamydia (p = NS).ConclusionsOral contraceptive pill and DMPA users differed with respect to both demographic factors and frequency of condom use. Odds of current Chlamydia infection did not differ between OCP and DMPA users when controlling for sexual risk-taking or demographic factors, though due to low Chlamydia rates in our population, this study was underpowered to detect this difference.

Adolescents with Medical Illness

Ensuring that pregnancies are anticipated and intended is particularly important for young women with medical illness. Many chronic diseases heighten the risk for adverse obstetrical and birth outcomes, while pregnancy may also exacerbate illness severity. This chapter covers contraceptive management in illnesses that are either commonly encountered among adolescents and young women or that are of such medical significance that they have great clinical and social impact on a young woman’s daily life, particularly in the setting of pregnancy. We provide an overview of the adolescent and young adult epidemiology of and recommended and contraindicated contraceptive methods for the following illnesses: asthma, history of bariatric surgery, cardiac anomalies, cystic fibrosis, deep vein thrombosis risk factors, diabetes, depression, disordered eating, epilepsy, headache disease (including tension and migraine), hypertension, inflammatory bowel disease, liver disease, sickle cell disease, systemic lupus erythematosus, and von Willebrand disease.