Justine Wu

Contraceptive nonuse among US women at risk for unplanned pregnancy

BACKGROUND This study was conducted to assess risk factors for contraceptive nonuse among a nationally representative sample of US women and explored the influence of future pregnancy intentions on contraceptive nonuse. STUDY DESIGN Using data from the 2002 National Survey of Family Growth (NSFG), we analyzed 12 months of contraceptive behavior among 3687 women at risk for unplanned pregnancy. RESULTS Compared with contraceptive users, contraceptive nonusers were more likely to be older than 40 years (OR 6.3, 95% CI 2.7-14.7), black (OR 1.8, 95% CI 1.2-2.8), less educated (OR 2.4, 95% CI 1.4-4.0), uninsured (OR 1.6, 95% CI 1.1-2.4), Medicaid recipients (OR 1.9, 95% CI 1.2-2.9) or having infrequent intercourse (OR 3.8, 95% CI 2.7-5.3). We found no significant association between future pregnancy intentions and contraceptive behavior. CONCLUSIONS While family planning efforts have traditionally focused on disadvantaged women, older women and women who have infrequent sex are also at high risk for nonuse. Future pregnancy intentions, as currently assessed by the NSFG, is not a useful indicator of contraceptive behavior.

Emergency contraception: A multispecialty survey of clinician knowledge and practices

OBJECTIVES To assess knowledge and provision of emergency contraception (EC), particularly the most effective methods. STUDY DESIGN A web-based survey was distributed to a cross-sectional convenience sample of healthcare providers across specialties treating reproductive-aged women. The survey was sent to 3260 practicing physicians and advanced practice clinicians in 14 academic centers between February 2013 and April 2014. We analyzed responses by provider specialty using multivariable logistic regression. RESULTS The final sample included 1684 providers (response rate=51.7%). Ninety-five percent of the respondents had heard of levonorgestrel (LNG) EC. Among reproductive health specialists, 81% provide LNG EC in their practice, although only half (52%) had heard of ulipristal acetate (UPA) and very few provide it (14%). The majority in family medicine (69%) and emergency medicine (74%) provide LNG, in contrast to 42% of internists and 55% of pediatricians. However, the more effective methods [UPA and copper intrauterine device (IUD)] were little known and rarely provided outside of reproductive health specialties; 18% of internists and 14% of emergency medicine providers had heard of UPA and 4% provide it. Only 22% of emergency providers and 32% of pediatricians had heard of the copper IUD used as EC. Among reproductive health specialists, only 36% provide copper IUD as EC in their practice. Specialty, provider type and proportion of women of reproductive age in the practice were related to knowledge and provision of some forms of EC. CONCLUSIONS Awareness and provision of the most effective EC methods, UPA and the copper IUD (which are provider dependent), are substantially lower than for LNG EC, especially among providers who do not focus on reproductive health. IMPLICATIONS In our sample of 1684 healthcare providers from diverse specialties who treat reproductive-aged women, knowledge and provision of the most effective forms of EC (UPA and the copper IUD) are far lower than for LNG EC. Women should be offered the full range of EC methods.

Knowledge and concerns related to the human papillomavirus vaccine among underserved Latina women.

Objective. This studys purpose was to assess knowledge and concerns related to the human papillomavirus (HPV) vaccine among underserved Latina women and Latina mothers of female adolescents and to explore differences between those in the vaccinated and those in the unvaccinated groups. Materials and Methods. We conducted cross-sectional written surveys of 206 Latina women at an urban health center in central New Jersey. Participants included vaccine-eligible women and mothers of vaccine-eligible adolescents. We calculated descriptive statistics, Fisher exact tests, and corresponding risk ratios (RRs) with 95% CIs. Results. Of those who had heard of HPV (71%), 80% knew that HPV is a sexually transmitted infection. Fewer understood the causative link between HPV and cervical cancer (58%) and genital warts (45%). Vaccine safety was the most frequently cited concern. Unvaccinated women and mothers of unvaccinated daughters were more worried that the vaccine could promote risky sexual behavior (RR = 1.6, 95% CI = 1.2-2.1) and more likely to believe that they or their daughters were not at risk for HPV infection (RR = 1.2, 95% CI = 1.1-1.4). Conclusions. To maximize HPV vaccination rates among underserved Latinas, concerns about vaccine safety, potential effects on sexual behavior, and self-perceptions of risk for HPV infection must be addressed.

Music for surgical abortion care study: a randomized controlled pilot study

BACKGROUND The study objective was to explore the effect of music as an adjunct to local anesthesia on pain and anxiety during first-trimester surgical abortion. Secondary outcomes included patient satisfaction and coping. STUDY DESIGN We conducted a randomized controlled pilot study of 26 women comparing music and local anesthesia to local anesthesia alone. We assessed pain, anxiety and coping with 11-point verbal numerical scales. Patient satisfaction was measured via a 4-point Likert scale. RESULTS In the music group, we noted a trend toward a faster decline in anxiety postprocedure (p=.065). The music group reported better coping than the control group (mean±S.D., 8.5±2.3 and 6.2±2.8, respectively; p<.05). Both groups reported similarly high satisfaction scores. There were no group differences in pain. CONCLUSIONS Music as an adjunct to local anesthesia during surgical abortion is associated with a trend toward less anxiety postprocedure and better coping while maintaining high patient satisfaction. Music does not appear to affect abortion pain.

Prevention of Unintended Pregnancy: A Focus on Long-Acting Reversible Contraception

This article summarizes the literature regarding the epidemiology and prevention of unintended pregnancy in the United States. Because of the Affordable Care Act and its accompanying contraceptive provision, there is a need for more primary care clinicians to provide family planning services. Office-based interventions to incorporate family planning services in primary care are presented, including clinical tools and electronic health record use. Special attention is paid to long-acting reversible contraceptive methods (the subdermal implant and intrauterine devices); these highly effective and safe methods have the greatest potential to decrease the rate of unintended pregnancy, but have been underused.

Women seeking emergency contraceptive pills by using the internet.

OBJECTIVE: To assess barriers and attitudes related to emergency contraception access among women seeking emergency contraceptive pills by using the Internet. METHODS: We conducted quantitative surveys and qualitative interviews of 200 women seeking emergency contraceptive pills from The Emergency Contraceptive Website (http://ec.princeton.edu). Main outcome measures included barriers to and attitudes toward emergency contraception access. RESULTS: Participants were predominately white, college-educated, urban residents. Women most frequently cited structural barriers to obtaining emergency contraceptive pills, such as inconvenient office hours. Although women supported advanced prescription of emergency contraceptive pills, there was less enthusiasm for nonprescription access because of concerns that others (but not they) would engage in risky sexual behavior. Women valued the consultation with a health professional; 42% stated they would still speak with a clinician even if nonprescription access was available. CONCLUSION: The Internet as a resource for emergency contraception appears limited to women of high socioeconomic status in our sample. There is a need to address beliefs that increased access to emergency contraception promotes risky sexual behavior because current evidence refutes this concern. Clinicians should still be prepared to discuss emergency contraception with patients, despite the fact that emergency contraceptive pills are now available to most (but not all) women without a prescription. LEVEL OF EVIDENCE: III

Use of Reversible Contraceptive Methods Among U.S. Women with Physical or Sensory Disabilities

CONTEXT Women with disabilities experience a higher rate of adverse pregnancy outcomes than women without disabilities. Preventing or delaying pregnancy when that is the best choice for a woman is a critical strategy to reducing pregnancy-related disparities, yet little is known about current contraceptive use among women with disabilities. METHODS A cohort of 545 reproductive-age women with physical disabilities (i.e., difficulty walking, climbing, dressing or bathing) or sensory disabilities (i.e., difficulty with vision or hearing) was identified from among participants in the 2011-2013 National Survey of Family Growth. Those at risk for unplanned pregnancy were categorized by whether they were using highly effective reversible contraceptive methods (IUD, implant), moderately effective ones (pill, patch, ring, injectable), less effective ones (condoms, withdrawal, spermicides, diaphragm, natural family planning) or no method. Multinomial regression was conducted to examine the association between disability and type of contraceptive used. RESULTS Some 39% of women with disabilities were at risk of unplanned pregnancy, and 27% of those at risk were not using contraceptives. The presence of disability was associated with decreased odds of using highly effective methods or moderately effective methods, rather than less effective ones (odds ratio, 0.6 for each), but had no association with using no method. CONCLUSION There is a significant need to reduce contraceptive disparities related to physical or sensory disabilities. Future research should explore the extent to which contraceptive use differs by type and severity of disability, as well as identify contextual factors that contribute to any identified differences.

A Web-Based Decision Tool to Improve Contraceptive Counseling for Women With Chronic Medical Conditions: Protocol For a Mixed Methods Implementation Study

Background Women with chronic medical conditions, such as diabetes and hypertension, have a higher risk of pregnancy-related complications compared with women without medical conditions and should be offered contraception if desired. Although evidence based guidelines for contraceptive selection in the presence of medical conditions are available via the United States Medical Eligibility Criteria (US MEC), these guidelines are underutilized. Research also supports the use of decision tools to promote shared decision making between patients and providers during contraceptive counseling. Objective The overall goal of the MiHealth, MiChoice project is to design and implement a theory-driven, Web-based tool that incorporates the US MEC (provider-level intervention) within the vehicle of a contraceptive decision tool for women with chronic medical conditions (patient-level intervention) in community-based primary care settings (practice-level intervention). This will be a 3-phase study that includes a predesign phase, a design phase, and a testing phase in a randomized controlled trial. This study protocol describes phase 1 and aim 1, which is to determine patient-, provider-, and practice-level factors that are relevant to the design and implementation of the contraceptive decision tool. Methods This is a mixed methods implementation study. To customize the delivery of the US MEC in the decision tool, we selected high-priority constructs from the Consolidated Framework for Implementation Research and the Theoretical Domains Framework to drive data collection and analysis at the practice and provider level, respectively. A conceptual model that incorporates constructs from the transtheoretical model and the health beliefs model undergirds patient-level data collection and analysis and will inform customization of the decision tool for this population. We will recruit 6 community-based primary care practices and conduct quantitative surveys and semistructured qualitative interviews with women who have chronic medical conditions, their primary care providers (PCPs), and clinic staff, as well as field observations of practice activities. Quantitative survey data will be summarized with simple descriptive statistics and relationships between participant characteristics and contraceptive recommendations (for PCPs), and current contraceptive use (for patients) will be examined using Fisher exact test. We will conduct thematic analysis of qualitative data from interviews and field observations. The integration of data will occur by comparing, contrasting, and synthesizing qualitative and quantitative findings to inform the future development and implementation of the intervention. Results We are currently enrolling practices and anticipate study completion in 15 months. Conclusions This protocol describes the first phase of a multiphase mixed methods study to develop and implement a Web-based decision tool that is customized to meet the needs of women with chronic medical conditions in primary care settings. Study findings will promote contraceptive counseling via shared decision making and reflect evidence-based guidelines for contraceptive selection. Trial Registration ClinicalTrials.gov NCT03153644; https://clinicaltrials.gov/ct2/show/NCT03153644 (Archived by WebCite at http://www.webcitation.org/6yUkA5lK8)

Long-acting Reversible Contraception—Highly Efficacious, Safe, and Underutilized

Each year, 43 million women, nearly 70% of all reproductive-aged femalesintheUnitedStates,areatriskforunplannedpregnancy.1 These women are candidates for contraceptive counseling and services. Unplanned pregnancies are associated with increased risks of maternal and child morbidity and mortality and socioeconomic costs to families and society.2 Nearly half of all US pregnancies are unplanned.2 Increasing access to long-acting reversible contraception (LARC) is a critical strategy for decreasing the US rate of unplanned pregnancy. LARC includes intrauterine devices (IUDs) and the subdermal implant. LARC is highly efficacious and associated with high rates of continued contraception.3 The majority of patients are medically eligible for LARC use. LARC is underutilized (14.3% of all contraceptive use) vs sterilization (28.2%) and hormonal contraception requiring user involvement (31.8%).4 Barriers to LARC include expense, misunderstanding about safety, and inadequate counseling.3 In 2016, the National Quality Forum endorsed LARC as one of several metrics for high-quality contraceptive care, underscoring the need for widespread patient-centered LARC counseling and access.5 Features of LARC Methods There are currently 1 copper and 4 levonorgestrel-containing IUDs and 1 progestin implant approved for contraceptive use by the US Food and DrugAdministration(FDA)(Table).Theprogestinimplantisplacedsubdermally with local anesthesia in the upper arm. LARC devices can be inserted and removed by trained professionals (including primary care clinicians) in the office setting without sedation. Evidence supports extended use of some LARC devices beyond the FDA-approved duration of use. The copper IUD is the most effective method of emergency contraception available (if placed within 5 d of unprotected intercourse; duration, 10-12 y); it inhibits fertilization through spermicidal effect. LARC provides greater efficacy compared with short-acting hormonal methods that require user involvement (eg, oral contraceptive pill, progestin shot, vaginal ring, contraceptive patch). Because LARC requires no user involvement, its effectiveness with typical use (eg, patient adherence) matches its theoretical efficacy with perfect use (>99%). In contrast, the effectiveness of oral contraceptives with typical use is substantially lower (91%) than theoretical efficacy with perfect use (>99%). Although the contraceptive mandate of the Affordable Care Act requires insurers to cover FDA-approved contraceptives without patient cost sharing, contraceptive coverage varies widelybasedonstateofresidence,insuranceplan,andemployer.Thus, Author Audio Interview

The politics of place: Presidential voting patterns and providers' prescription of emergency contraception

OBJECTIVE The most effective forms of emergency contraception (EC) require a prescription or a medical procedure; therefore, provider willingness to offer EC remains critical to patient access. This study seeks to assess whether political alignment of a providers county is associated with provider attitudes and behaviors regarding EC. STUDY DESIGN We analyzed survey data collected from 1313 healthcare providers from February 2013 to April 2014 at 14 academic medical centers in the United States. Using logistic regression, we estimated associations between the county political alignment of a providers practice and his or her EC-related beliefs and practices: 1) if the provider is aware of the most effective EC methods; 2) if knowing that a hypothetical EC method prevented implantation would make a provider less likely to prescribe that method because of personal ethical or religious reasons; and 3) if the provider prescribes any form of EC in his or her practice. RESULTS In multivariate models, a one percentage-point increase in county Republican vote share was associated with a 2.9% decrease in the odds of a provider prescribing EC, after accounting for provider knowledge and attitudes about EC. CONCLUSIONS EC provides a critical last chance to prevent pregnancy after unprotected sex, yet women living in Republican-leaning counties may face difficulty obtaining EC from healthcare providers. Programs seeking to improve access to EC should focus on areas likely to have fewer providers willing to prescribe EC, which may be those that are more Republican-leaning. IMPLICATIONS The most effective forms of emergency contraception require a prescription or a medical procedure; therefore, provider willingness to offer EC remains critical to patient access. Women living in Republican-leaning counties may face difficulty obtaining emergency contraception from healthcare providers.