Irma Dahlquist

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.

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.

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.

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.

Pre-pregnancy and Early Prenatal Care are Associated with Lower Risk of Ectopic Pregnancy Complications in the Medicaid Population: 2004-08.

BACKGROUND Ectopic pregnancy causes significant maternal morbidity and mortality. Complications are more common among women with Medicaid or no insurance compared to those with private insurance. It is unknown whether preventive care prior to pregnancy and prenatal care, which are covered by Medicaid, would decrease complications if they were more fully utilised. METHODS Medicaid claims were used to identify a clinical cohort of women who experienced an ectopic pregnancy during 2004-08 among all female Medicaid enrolees from a large 14-state population, ages 15-44. Diagnosis and procedure codes were used to identify ectopic pregnancies and associated complications. The primary outcomes were complications associated with ectopic pregnancy: blood transfusion, sterilisation, or hospitalisation with length of stay greater than 2 days. Independent variables were documentation of preventive care within 1 year prior to the ectopic pregnancy and prenatal care within 4 months prior. RESULTS Controlling for race, age, and state of residence, womens risks of any ectopic pregnancy complication were independently higher among those who did not receive any Medicaid-covered preventive care within 1 year before the ectopic pregnancy compared to those who did (RR 1.12, 95% confidence interval (CI) 1.09, 1.16), and among those who did not receive any Medicaid-covered prenatal care within 4 months prior, compared to those who did (RR 1.89, 95% CI 1.83, 1.96). CONCLUSIONS Pre-pregnancy and prenatal care are independently associated with decreased risk of ectopic pregnancy complications among Medicaid beneficiaries.

Provision of abortion and other reproductive health services among former Midwest Access Project trainees

OBJECTIVE The Midwest Access Project (MAP) offers opt-in training to students, residents and practicing clinicians in reproductive health care including abortion. We surveyed MAP alumni to identify current practice characteristics and assess predictors of reproductive health service provision. STUDY DESIGN We sent an online survey to alumni of MAPs Individual Clinical Training program, 2007-2015 (n=127). The primary outcome was current provision of any abortion service. Secondary outcomes included providing specific abortion services and other reproductive services. RESULTS We received responses from 61% of eligible MAP alumni (n=77 out of 127). The majority reported a specialty of Family Medicine (68%) and current location in the Midwest (52%). Among current residents, fellows or clinicians practicing in a field whose scope includes abortion (n=56), 50% provide abortion. Most (84%) provide outpatient miscarriage management, and nearly all (≥96%) provide pregnancy options counseling and full scope contraception. Respondents who received the most advanced training in medication abortion as part of their MAP training were more likely to report providing abortion in their current practice than those who did not (63% vs. 32%, p=.027), as were those who completed more than one MAP rotation compared to those who completed one rotation (100% vs. 44%, p=.009). CONCLUSIONS Half of MAPs alumni provide some abortion care. Nearly all provide comprehensive counseling and contraceptive services. IMPLICATIONS Opt-in training is a promising strategy to develop providers of comprehensive reproductive health care.